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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Lincoln Couuty <br />M-1984-185 <br />Ellis Allen Pit <br />February 28,2005 <br />R~~~sVR® <br />~8 ~ , ~/~, <br />Division of Mlnera/s V tR <br />and~epl~ <br />$281.00 (Due on or before your anniversary date) <br />Lincoln <br />L~0 <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 current disturbances to affected <br />- - -'-land-reclamation~ccomplished-to-date-and-during-the_preceding.yeas,-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 your revised written annnal report end annnal renort m to this form. please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice 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: Don Blake <br />Permittee Name: Lincoln County <br />Address: P.O. Box 39 <br /> Hugo, CO 80821 <br />Phone Number: (719) 743-2337 <br />Fax Number: (719) 743-2815 - <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 />~9~ .~~ <br />Signature of Corporate Officer, Owner, or Designee <br />~1- p•'7- <br />Date <br />MiPERMITNdASTERDOCUMEMSNI-AF-04 <br />