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<br />III IIIIIIIIIIIII III ~ ~ r-^ ~, ~~ ~~, Encl osure <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date <br />David Goss <br />M-85-140 <br />Goss Sand & Gravel <br />01/24/89 <br />JAN ? 71989 <br />M1h1Eb l..~fVD <br />IiECLAM,41`IOId I~IVI$IpP~ <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />Check or money order ~dyabl.e to Colorado Mined Land Reclamation <br />Division for annual fees due <br />Annual Report <br />Remarks: <br />