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VU~ <br />ANNiIAi. FF,F, and RF,PORT RF.(7iTFST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />George F. Gallegos T '- - <br />;~i-1983-164 <br />Gallegos Pit <br />August 25, 2005 <br />RE(:EIVE~'~ <br />AUG 1 5 2005 <br />~' <br />,~ Division of Minerals ~;~_ i.::;;e,y <br />1 <br />$281.00 (Due on or before your anniversary date) <br />Conejos <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 operator <br />-shsll-su?~mit=the-stmual-fee,-a-report and-mzp-showing-the-extent-of-c~u-re~ ciisturtanses-to_affeeted-land, J <br />reclamation accomplished to date and during the preceding yeaz, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach y~nur revised written anm~al rennrt and anneal rennrt man to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: George F. Gallegos <br />Permittee Name: George F. Gallegos <br />Address: <br />Phone Number: <br />Fax Number: _ <br />P.O. Box 575 <br />Romeo, CO 81148 <br />(719) 843-5113 <br />~~~ _ _ 1 <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 />~f ~' / V .is--v~~ °f-~ <br />Signat~u-re o~f orpo/rate Officer, Own r or Designee <br />7r/ L6 //l ,5 ~ <br /> <br />Date <br />