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i <br /> <br />Permit No: 77-560 <br />Anniversary Date: February 22 <br />Operator: <br />Please complete t'ie following and return this form with your fees and reclama- <br />tion data. <br />' Enclosed are: (Check box(es)1 <br />Check or money order payable to Colorado Fiined Land Reclama- <br />ti on Division for annual fees due <br />Annual Repott <br />hla p <br />Remarks <br />Signed, <br />• <br />