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<br />N '~ <br />~?~~=X89/~~t <br />JUN 1 4 2C05 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Phillips County <br />M-2003-024 ~~ <br />Ward Pit <br />May 15, 2005 <br />$281.00 (Due on or before your anniversary date) <br />Phillips <br />llivisian of PG;ac;xia & GaulaOV <br />According to C.R.S. 34-32.5-116 or C.R.5. 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 ~nur revised written annual report and anm~al report map to his 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: Randy Schafer <br />Permittee Name: Phillips County <br />Address: 221 S.Interocean Ave. <br />Holyoke, CO 80734 <br />Phone Number: (970) 854-3778 <br />Fax Number: (470) 854-3811 <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 />~nm ~ <br />Signature CorporatesUtFicer, Owner, or Designee <br />Date <br />M:~PEAMITMASTERDOCUMENTS~M-AF-04 <br />