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<br />RECE~dEE? <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Montezuma County <br />M-1985-031 <br />Mancos Gravel Pit <br />May 31, 2004 <br />APR 1 '~ 2004 <br />Giuiaaa of ~9imrals ~ Geolapy <br />$688.00 (Due on or before your anniversary date) <br />Moutezuma <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each yeaz, 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 ynnr revised written annnal rrnnrt and annnal re~n~t to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written <br />report. <br />Division records indicate the following petmittee contact information. Please verify and make any necessary <br />changes: <br />Pennittee Contact: <br />Permittee Name <br />Address: <br />Phone Number: <br />Fax Number: <br />Lloyd Everett <br />Montezuma County <br />1680 Hwy. 145 <br />Cortez, CO 81321 <br />(970)565-8666 <br />(970)565-8252 <br />If you have additional comments and/or information that should be provided to the 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 />ign moire f Corporate Of£cer, weer, or Designee <br />Date <br />S-~ <br />No ~~,.tz~~ ~~ a~ 3 <br />N:IPERM IT.M ASTERDOCUMENTSUI-AF-04 <br />