2006-08-18_REPORT - M2003092

• Permit No: M2003092
• IBM Index Class Name: Report
• Doc Date: 8/18/2006
• Doc Name: Annual Fee/Report/Map
• From: Nick H. Gray
• To: DRMS
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
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/~ ANNiiAi, FF.F, and REPORT RF.Oi1F.ST
'~ Nick H. Gray
t~2003-092
RECEIVED
'~CUG 18 2006
~rvM n ngtand Safety n
Gray Pit #I
June 29, 2006
$688.00 (Due on or before your anniversary date)
Montrose
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,
rec-tamatiiin accomp isfied-to date and3uring"the preceding year, new disturbances-that are antic~pafed to ocour
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 attarh xpnr reviced written anm~al report and anmial rennrt m ~n to thic 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: Nick H. Gray
Permittee Name: Nick H. Gray
Address: 584 65.30 Rd.
Montrose, CO 81401
Phone Number: [phone]
Fax Number:
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.
gnature of Corporate Officer, er, or Designee
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Date