2005-08-17_REPORT - M1981309

• Permit No: M1981309
• IBM Index Class Name: Report
• Doc Date: 8/17/2005
• Doc Name: Annual Fee/Report/Map
• From: Washington County
• To: DMG
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Washington County ~'~'t~l
/M-1981-309
V.F. Smith Pit #5
August 27, 2005
t/I~UG 17 2005
rJivision of F~Sincrn~a L GeoloBtl
$281.00 (Due on or before your anniversary date)
Washington
According to C.R.S. 34-32.5-116 0~ C.R:S-34=3Z=I1-b each year; on the anniversary-date-of-the-permit; an- --
operator-shall-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 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 y~nnr revised written annnal re,~nrt and annnal re~nrt main 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: Larry Champ
Permittee Name: Washington County
Address: P.O. Box 32
Phone Number:
Fax Number:
Anton, CO 80801
[phone]
[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.
(',~°
magna re of rporate Offi r, Owner, or Designee
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Date
M:~PERMI'r4MASTERDOCUMENTSNI-AF-04