2006-08-30_REPORT - M1984136

• Permit No: M1984136
• IBM Index Class Name: Report
• Doc Date: 8/30/2006
• Doc Name: Annual Fee/Report/Map
• From: Prowers County
• To: DRMS
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

C~
G' ANNUAL FEE and REPORT REQUEST
PERMITTEE NAME:
PERMff NO.:
OPERATION NAME:
ANNNERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
`~ /Prowers County
/ M-1984-136
Brann Pit
August 31, 2006
REC'~1VED
AUG 3 0 ?D08
DlvMlning aRedamanon.
d Safety
$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
operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected
land, reclamation-accomplished-to date and-during the preceding year,.new disturbances thatare anticipated to _
occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach your revised written annual report and annual report mau 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: Mark Dorenkamp
Permittee Name; Prowers County
Address: 109 E. Sherman St.
Lamar, CO 81052
Phone Number:
Fax Number:
[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.
/~~~
ignature of Corporate Officer, Owner, or Designee
~'7~G
Date
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