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C~'r 5 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Washington County <br />M-1981-309 <br />V.F. Smith Pit #5 <br />August 27, 2004 <br />~~~~~(~/ED~ <br />AUG 1 9 2004 <br />Division of Minerals & Geology <br />$281.00 (Due on or before your anniversary date) <br />Washington <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 cun•ent disturbances to affected <br />- land-reclamation accomplished-to-date-and-ducing_the_preceding_year,-new disturbances_thatare_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 ymrr revised written ann cal re~7nrt and anneal report m T to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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: Larry Champ <br />Permittee Name: Washington County <br />Address: P.O. Box 32 <br />Anton, CO 80801 <br />Phone Number: <br />Fax Number: <br />(970)383-3216 <br />(970) 345-2702 <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 />Sit'gnature of rporate O tcer, Owner, or Designee <br />~ ~ 2. d-5~ <br />Date <br />~~ ~ nod Gtatrz <br />~ rn~-p b -~ ~~i 5 ~!'~ <br />M:~PERMI'M1AS7ERD000MENTS Wf-AF-04 <br />