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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Kym A. Schure <br />M-1986-074 <br />Dollerschell Pit <br />June 30, 2004 <br />RECEI!/E® <br />AUG 2 7 2004 <br />Division of Minerals & Geology <br />$281.00 (Due on or before your anniversary date) <br />Logan <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 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 map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />--Pe>mittee°Coniact:~£ym71-Schure - -------- - <br />Permittee Name: Kym A. Schure <br />Address: 12826 CR 37 <br /> Sterling, CO 80751 <br />Phone Number: (970) 522-9485 <br />Fax Number: <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 enclosed. <br />_ ~ ~~ ~- <br />Signat of Corporate Officer or Owner <br />~~~-~~ <br />Dates <br />