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/~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Phillips County <br />M-1994-007 <br />Johnson Pit <br />May 23, 2003 <br />RECEIVED <br />MAY D 5 pdp3 <br />llivision of Minerals and Geology <br />$688.00 (Due on or before your anniversary date) <br />Phillips <br />According to C_R.S. 34-32,5-llti or C.R.S. 34-32-116, each year, on the -anniversary date of the ermit an <br />~ r s u5rnit the aiinual-fee, a report and map showing t e extent o 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 ynnr revised written anneal rennrt and anm~al reRprt mad 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: Randy Schafer <br />Permittee Name: Phillips County <br />Address: 221 S.Interocean <br />Phone Number: <br />Fax Number: <br />Holyoke, CO 80734 <br />(970)854-3778 <br />(970) 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 />C.G)~c/ ~!i11O~U1 <br />Signature of orporate Of cer, Owner, or Designee <br />5/z/a3 <br />Date <br />M:\PERMITVv1ASTERDOCUMENTSVv1-AF-04 <br />