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• <br />Permit xo: 76-56 <br />Anniversary Date: <br />operator: <br />February <br />Please complete the following and return this form with your fees Bind reclama- <br />tion data. <br />Enclosed are: (Check box(es)) <br />Check or money order payable to Colorado Mined .[.and Reclama- <br />tion Division for annual fees due <br />Annual Report <br />Map <br />Remarks <br />signed, <br />