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<br />Permit fJo: 81-121 <br />Anniversary Date: July 23 <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 />Check or money order payable to Colorado t4ined Land ~ 0 p <br />_ Reclamation Division for annual fees due <br />Annual Report <br />Remarks: <br /> <br />Signature <br />