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<br />Permit Ro: 77-94 <br />Anniversary Date: _December <br />Operator: <br />Please complete the following and retarn this form with your fees and reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />Check or money order payable to Colorado Mined Land Reclama- <br />Q ti on Division for annual fees due <br />Annual Report <br />Map <br />Remarks <br />Signed, <br />