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i <br />Permit No: 80-228 <br />Anniversary Date: April 27 <br />~ Operator: Leonard W. & Rebecca S. Lloyd <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 the Colorado Mined Land <br />~ Reclamation Division for annual fees due <br />_ Annual Report <br />Signature <br />