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~ ~ - .. <br />Permittee Name: <br />Permit No: <br />~ Operation Name: <br />Anniversary Date: <br />• <br />Goodell Brothers Inc <br />M-77-522- <br />HERMAN FEIT PIT <br />03 /23 /B6 <br />~~ <br />;`.`;. il2r'fifclosure <br />11 {; <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 Color~ido Mined <br />Land Reclamation Division for annual i'ees due <br />Annual Report <br />V Map <br />Remarks: ('t il f(.cc~ hi.~- L ~ G/ J~`~ - .33'~~/ ~JD~i.,~ ~,~ <br /> <br />C eJi tc. m OZ'S L <br />Signature <br />