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<br />Permit Vo: 79-181 <br />Anniversary Date: September 1 <br />Operator: <br />Please complete the following and return this form with your fees and <br />reclamation daia. <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 />Remarks: <br />iynature <br />