2005-08-11_REPORT - M1984140

• Permit No: M1984140
• IBM Index Class Name: Report
• Doc Date: 8/11/2005
• Doc Name: Annual Fee/Report/Map
• From: Prowers County
• To: DMG
• Media Type: D
• Archive: No

f ~~
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Prowers County ~ ' " "
~jM/1984-140
Walker Pit North
August 31, 2005
~~
.s~ a
~~~~ :~;
t/PU~ 1 ~ ti~p5
J.otoQtl
$281.00 (Due on or before your anniversary date)
Prowers
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
aperatorshall-submit-the annual-fee; a-report and-ntap-showing-tl~e~ctent-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 yeaz, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach ymrr revised written anmial report and anm~al rennrt m ~n 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: Mazk Dorenkamp
Permittee Name:
Address:
Phone Number:
Fax Number:
Prowers County
109 E. Sherman St.
Lamar, CO 81052
[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.
Signature of~at~~er, Owner, or Designee
~- Z ~~~
Date
M:~PERMITwfASTERD000MEMSVA-AF-04