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li <br />Permit No: 7~Jc_45 <br />Anniversary Date: February 2R <br />Operator: <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />Check or money order pay able .to Colorado Mined Land <br />/ Reclamation Division for annual fees due <br />Annual Report <br />'~ Map <br />Remarks <br />