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<br /> <br />Permit No: 81-276 HERTZOG PIT <br />Anniversary Date: Julv 22 <br />Operator: <br /> <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 />Reclamation Division for annual fees due <br />~i Annual Report <br />hlap <br />Remarks: <br />re <br />