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<br />Permit No: 81-235 <br />Anniversary Date: ~pri7 77 <br />~ Operator: <br />Please complete the following and return this form with your fees and reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />~ Check or money order payable to Colorado Mined Land Reclama- <br />ti on Division for annual fees due <br />® Annual Report <br />Map <br />Signed, / /`~ ~, / /~ <br />