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<br />Pennit No: 80-146 <br />Anniversary Date: May 1 <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 Wlined Land <br />_ Reclamation Division for annual fees due <br />Annual Report <br />Remarks: <br />Siynature <br />