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<br />Pentiit No: 82-36 MESA GRAVEL PIT <br />Anniversary Date: June 22 <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 payable to Colorado Mined Land <br />X Reclamation Division for annual fees due <br />Annual Report <br />Map <br />.~L <br /> <br />Remarks: see attached report <br />Signature <br />