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'~ <br />• Permit No: <br />80-135 <br />Anniversary Date: October <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 />Remarks <br />• <br />Annual Report <br />I-'-1 Map <br />Check or money order payable to Colorado Mined Land <br />i~ I Reclamation Division for annual fees due <br />Signed, <br />• <br />