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<br />ANNT1Ai, P+FF and REPORT RF<7TTFST F$~C~~kPw~~ <br />PERMITTEE NAME: Montezuma County ~~T I i~ ~~~4 <br />PERMIT NO.: - _ _~ Division at Mir,Erai. t ?z~mp~; <br />OPERATION NAME: Tozer Pit <br />ANNIVERSARY DATE: m er 2, 2004 <br />ANNUAL FEE DUE: $688.00 (bue on or before your anniversary date) <br />COUNTY: Montezuma <br />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 <br />operator shall submit the_ annual fee, a report and map showing the extent of-current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual red nrt m~ to this form. Please note Yhal an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: <br />Permittee Name <br />Lloyd Everett <br />Montezuma County <br />Address: <br />Phone Number: <br />Fax Number: <br />1680 Hwy. 145 <br />Cortez, CO 81321 <br />(970)565-8666 <br />(970)565-8252 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />~~ <br />gnature of otporate Officer, Owner, or Designee <br />i~ /~~c~~ <br />Date <br />~C ~t~v~ ~~, r~ lc ~ ~Tc~ ~~f~ <br />M iPERMITVNASTERDOCUMENTSVd-AF-04 <br />