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' ~ - • III III IIIIIIIIII 111 <br />I 999 <br /> <br />Permit Igo: 77-519 <br />Anniversary Date: August 28 <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 f~lined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />Signature <br />