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<br /> <br /> <br /> <br />Permit No: 79-45 <br />Anniversary Date: F <br />28 <br /> <br />Operator: . <br />Please complete the following and return this form with your fees and reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />Remarks <br />Check or money order payable to Colorado h.~ined Land Reclama- <br />ti on Division for annual fees due <br />Annual Report <br />Map <br />Signed, <br />