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• i <br />Permit No: 80-49 <br />Anniversary Date: Febroa ry 18 <br />Operator: <br />Please complete the following and return this form with your fees and reclamation <br />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 />O Annual Report <br />• Remarks <br />Signed, <br />M <br />