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' ~ • <br />Permit No: 73-7 <br />Anniversary Date: Januarv 7 <br />Operator: <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 />Annual Report <br />~ Map <br />Remarks <br />c. ~J.~..~-~~ <br />Signed <br />