2005-08-08_REPORT - M1995026

• Permit No: M1995026
• IBM Index Class Name: Report
• Doc Date: 8/8/2005
• Doc Name: Annual Fee/Report/Map
• From: Custer County
• To: dmg
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Custer County
M-1995-026
Gravel Pit M-093
August 24, 2005
AUG 0 8 2005
Oivisian ~. ~.~,:~~~-•s zed Geology
$688.00 (Due on or before your anniversary date)
Custer
_ _ _ _,_ _-_ According_to C.R.S._34,32.5-1.16 or_C.R.S._34.32-116, each year, on. the- anniversary date-of-the permit,-an - -- ---
-~ ~operatorshall_submit the-annual fee,_a-report_and_map_showing the extent of_current disturbances to_affected,__ _
land, reclamation accomplished to date and during the preceding year, new disturbances that aze anticipated to
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 for the year, if any.
Please attach ynnr revised written annual rennrt and anneal repnrf m,~ to this form- Please note that an
adequately labeled map that clearly delineates and includes the above elements may since for a written
report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Gary L. Havens
Permittee Name:
Address:
Custer County
P.O. Box 1669
Westcliffe, CO 81252
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 and map. Annua] Report instructions are
enclosed.
Signature of r rte Officer, Owner, or Designee
~-/- 6~
Date
M:~PERMIr1MASTERDOCUMENTSVv1-AF-04