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~~ <br />Permittee Name: <br />Permit No: <br />Operation Name: <br />Anniversary Date: <br />~I~ I~~~I~II~~~~~I~~ <br />999 <br />111/112 Enclosure <br /> <br />Goodell Brothers, Inc. <br />Id-77-522 <br />Herman Feit Pit <br />03/23/89 <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 />tdap <br />Remarks: <br />~~ ~~ <br />Signature <br />