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<br />Permit No: 78-52 <br />Anniversary Date: June <br />Operator: <br /> <br />Please complete the following and return this form with your fees and reclama- <br />tion data. <br />snclosed are: (Check box(es)) <br />Check or money order payable to Colorado Mined Land Reclama- <br />Q/ tion Division for annual fees due <br />Annual Report <br />hfap <br />Remarks <br />Signed, ~ <br />