REP02787

• Permit No: M1999073
• IBM Index Class Name: Report
• Doc Date: 2/7/2002
• Doc Name: 2002 Annual Report
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE
ANNUAL FEE DUE:
COUNTY:
According to C.R.S. 34-32.5-116 or C.R.S. 34-32-I 16, each year, on [he anniversary date of [he permit, an operator
shall submit [he 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 are 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 your revised written annual reuort and annual report mau to this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may suffice for a written report.
ANNUAL FEE and REPORT REQUEST
Evan L. Melby, Inc.
M-1999-073
Pit 1
February 7, 2002
$281.00 (Due on or before your anniversary date)
Costilla
Division records indicate [he following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact
Evan Melby
Evan L. Melby, Inc.
Permittee Name:
Address:
P.O. Box 4159
Ventura, CA 93007
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. Annual Report instructions are enclosed.
`"~'~. ~
Signature of Corporate Officer or Ow
2~lo~OZ
Date
M:~PERMITMASTERD000MENTSNI-AF-01