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~ ~ -iiiiiiiiiiiii iii ~ <br />iii <br />999 <br />Permittee Name: David Goss <br />M-85-140 <br />Permit No: Goss Sand & Gravel <br />Operation Name: 01/24/87 <br />Anniversary Date: <br />110 Enclosure <br />JAN 291987 <br />MINED LAND <br />[lECLAMATION DIVISION <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 payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />Annual Report <br />Remarks: <br /> <br />it b <br />Y fy <br /> <br />SiglSature <br />P <br />i ~~~~~ <br />~.~~ <br />F; -~. <br /> <br />