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Permit No: 77-410 <br /> Anniversary Date: November 3 <br /> Uperator: <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 /> Remarks: <br /> gnature <br />