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<br />Permit No: 77-141 <br />Anniversary Date: December 29 <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 />- Annual Report <br />Map <br />Remarks <br /> <br />Signed <br />