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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~II ~I~II~II~~~~~ ~II <br />999 <br />ANNUAL FEE and REPORT REQUEST RECEIVED <br />Phillips County MAY 2 3 2~^1 <br />M-1994-007 Division of Minerals and Geology <br />Johusou Pit <br />May 23, 2001 <br />$550.00 (Due on or before your anniversary date) ~~ ~ ]ti l~ <br />Phillips <br />`' 3p <br />According to C.R.S. 34-32.5-I 16 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an <br />operator shall submit the annual fee, a report and map showing the extent of 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 your revised written annual resort and annual report maa to this form. Pleose note that an <br />adeguntely lnbeled map that clearly delineates and includes the above elements may suffice jor 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 />Holyoke, CO 80734 <br />Phone Number: (970) 854-3778 <br />Fax Number: (970) 854-3811 <br />If you have additional comments and/or information that should be provided to [he 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 />G~ . ~~1~t1,1~ <br />Signatur o Corpor e Officer or Owner <br />.3'~zi~o <br />Date <br />M. W ERM ITMASTERDOCUti¢NTSUI-AF-OJ <br />