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Permit No: 79-205 CHAMBERS PIT <br /> Anniversary Date: August 15 <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 Mined Land <br /> _ Reclamation Division for annual fees due <br /> —L!/ Annual Report <br /> Map <br /> Remarks -/j C' A4 <br /> ?ed <br />