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<br />Permit No: 80-136 <br />Anniversary Date: February 25 <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 />Map <br />Remarks <br />~+yneu <br />