2005-06-07_REPORT - M1983001

• Permit No: M1983001
• IBM Index Class Name: Report
• Doc Date: 6/7/2005
• Doc Name: Annual Fee/Report/Map
• From: Washington County
• To: DMG
• 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:
Washington County
M-1983-001
Cecil 11-34-49
May 16, 2005
$281.00 (Due on or before your anniversary date)
Washington
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JUN 0 ~ 2005
[lieisicr o4 it'I:.~nrais t5 Gealopy
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 fo affected_ _ ___
land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to I
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 ynnr revised written anm~al re~nrt and anmial re; nn rt main 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: Larry Champ
Permittee Name: Washington County
Address:
Phone Number:
Fax Number:
150 Ash
Akron, CO 80720
[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 aze
enclosed.
S gnatu a of Co rate Officer, caner, or Designee
., 1 _ ~,~;
Date
M:~PERMIIINASTEADOCUMENTSU.I-AF-04