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NNI \I. FF'F and RF:1'OR1' I(Fx~l l•sr RECE~!~~E <br />' <br />' <br />' ~-JUL 28 1006 <br />' <br />IfI. N:1ML: <br />I <br />I.I(~Ifl <br />I rcuumt (bunts <br />- F <br />I'I:R\11'I NU.: M1I-1994-i IA .- ~~ ~: ~ : ~.~ v~,. ..::.. ~:.,~, ~ <br />l)I'I•k;\'llON NAMI{: Phantom ('anvon 1'it <br />ANNI\'I•I(yAl(ti' I);\ 11• Auka,t 1(, 20116 <br />1NN1 t;\ I I1' I UI U. 5281.1111 I I)uc on or bcfurc your anniccrsnry <lutcl <br />r 't H IX'I'1' l cllcr <br />Accurchng to (.I(.ti. i-1.3?.$•I I6 or ('.R.S. id•J2-I 16, Inch ycnr, un the nnnlvcrsnry dote of the perms, an <br />operator shall subnut the annu:d Ice, a rcpon and map ;howmg the cctcnt of current Jtsturhanccs to at)cetcd <br />Lind, rccl;unauurt acrumph;hcd to date :uul Jurmg the prcccdmg scar, new Ji;Wrfruucs Ihat arc annctpatrd a, <br />occur dunng the upeommg yr:u. reclamaGnn that will he pcrtimnrd during the cummg ycnr. the date; (ur the <br />hegutnmg of active operations. and the date active ol)cranuns ceased lix the ycnr, tl'any. <br />I'Ic:uc attach your rc~iscd wriucu annual rcuurt and annual rcuurt mop br this form. /'lr~ue n~+rr rh~rr un <br />udcyuateM lrtheled nugr Nrat clew•!r delineates arrd Au•ludec !de ahnre elemewls mrrc suJ/ice%nr a aritle~ <br />rcpnr[. <br />Ihvismn rrcords indicate the li,llowutg pcrntittcc contact mlLrmaGun. Plcuxc verify and mukr any neces.ar <br />chances: <br />PrrnuUcc l'imlact: !'crrv :!epos <br />I'ennittcc Name: fremunt County <br />Addrc~s: ('aunh• C'ummts,u>ncrs <br />615 M11ncun Ave.. I(unnt A105 <br />('anun(ltv,('O !+1212 <br />Phone Number: l'I')I 2?<~ ';!!tl <br />Fas Number: 17191 276-7 ~O4 <br />li you have addnianal aunmcnis and; or mtinmalum that should be pnxtdcd to the 1)ivrswn, plru;c provuic rl <br />below or crunch it lu thi; li~rnt Gong wuh your written report anJ map. Annual Report iminteUun> urc <br />cnrlu,cd. <br />tiignamre of ('ut ur:ue Ultircr. Owner, ur hcsipnee <br />7 /iLo 6 <br />Date <br />