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/ ` CJ <br />APR i? : znoZ <br />ANNUAL FEE and REPORT REQUEST <br />RECEI!"~~ <br />PERMITTEE NAME: Baca County APR 1 0 20~? <br />PERMIT NO.: M-1995-019 <br />OPERATION NAME: Mundell Estate No. 32 UiYtsion of Minerals and Geology <br />ANNIVERSARY DATE: May 1, 2002 <br />ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br />COUNTY: Baca <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 [he 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 vour revised written annual report and annual report man to this form. Please Mote that air <br />adegttare[y labeled map that clearly delineates and includes the above elements may suffice for a written <br />report. <br />Division records indicate [he following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Ray Miller <br />Permittee Name: Baca County <br />Address: 741 Main St. <br />Springfield, CO 81073 <br />Phone Number: (719) 523-6532 <br />Fax Number: (719) 523-6584 <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 />Signature of Corporate Officer or Owner <br />Date <br />r <br />i~/'~.[~ 1/J~~,~IJ <br />M iPGRM17U1ASTLRD000M ENI'SU1-A F-04 <br />