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<br />Permit No: 77-558 <br />Anniversary Date: February 22 <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 P.eclama- <br />ti on Division for annual fees due <br />N <br />Annual Report1~~.r \`,~\`~ <br />Map <br />Remarks <br />Signed, <br /> <br />