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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />RECEIVED <br />Holyoke Gun Club <br />M-1977-075 <br />Holyoke Gun Club Pit <br />September 27, 2002 <br />$281.00 (Due on or before your anniversary date) <br />Phillips <br />SEP 1 0 2002 <br />Division of Minerals and Geology <br />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 <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual report map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following pemtittee contact information. Please verify and make any necessary <br />changes: I, <br />Permittee Contact: Gary Hershfeldt fir! "" / eYl <br />Permittee Name: Holyoke Gun Club <br />Address: 20358 CR 45 <br />~~ <br />Holyoke, CO 80734-9507 <br />Phone Number: (970) 854-3641 <br />Fax Number <br />If you have additional comments and/or information that should be provided to [he Division, please provide <br />below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />~~ <br />~~~~D <br /> ~ <br />I: .~ <br />Signature of Corporate Officer, Owner, or Designee <br />~, ~a <br />Dad , <br />M:~PERM ITw1ASTERD000MENTSVN-AF-01 <br />