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r- <br />. r< <br />Permit No: 77-300 <br />Anniversary Date: October 28 <br />Operator: <br />C~ <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: <br />Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />_ hiap <br />Remarks: <br />~ .~~,--rte <br />Signature <br />