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' __ <br />Permit f•~o: 79-192 <br />Anniversary Date: October <br />Operator: <br /> <br />Please complete the rollowing and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />_ Check or money order payable to Coloraao Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />Remarks: <br />Signature <br />