2004-10-29_REPORT - M1983177

• Permit No: M1983177
• IBM Index Class Name: Report
• Doc Date: 10/29/2004
• Doc Name: Annual Fee/Report/Map
• From: Bent County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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6M k
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Bent County
M-1983-177
Adams Pit
November 2, 2004

RECEI~!L®
OCT 2 9 2004
L..... . ~eolag4
$281.00 (Due on or before yom~ anniversary date)
Bent
According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an
operator shall submit the annual fee, a report and map showing the rxtent of current disturbances to affected
- land,=reclamation>scsoznplishc~- --date-and-during-the preeeding•year,-new-disturbances thaYare'aniicipated-fo-
occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the
beginning of active operations, and the date active operations ceased fir the year, if any.
Please attach ynnr revised written annnal re~nnrt and annual rent m ~n to this form- Please note that an
adequately labeled map that clearly delineates and includes the aiiove elements may since for a written
report.
Division records indicate the following petmittee contact informatiotr. Please verify and make any necessary
changes:
Permittee Contact: Gary Pritchard
Permittee Name: Bent County
Address: P.O. Box 350
Las Animas, CO 81054
Phone Number: [phone]
Fax Number: [phone]
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report anal map. Annual Report instructions are
enclosed.
~~~~~~~~ C-~~i~~~
Signat} e of Corpora e Officer, Owner, or Designee
O/c`PO.BEit J.~j' .ZoOh~
Date
M:~PEAMIIIMAS7ERDOCUMENTSUI-AF-04