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<br />Permit No: 77-306 //~~ <br />Anniversary Date: Seotember103 <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 />1L Check or money order payable to Colorado Mined Land <br />~~Rec~lamation Division for annual fees due <br />- Annual Report <br />Map <br />Remarks <br /> <br />Signed <br />