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. • i <br /> Permit No: 79-165 <br /> Anniversary Date: October 25 <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 /> Check or money order payable to Colorado Mined Land Reclama- <br /> tion Division for annual fees due <br /> Annual Report <br /> Map <br /> Remarks <br /> Signed, <br />