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<br />112 Enclosure <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date: <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />V Check or money order payable to Colorado Mined <br />Land Reclamation Division for annual fees due <br />V / Annual Report <br />V Map <br />Remarks: See enclosed report. <br />Si <br />