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.~ <br />if <br />y~ <br />PERMTITEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Baca County <br />M-1995-019 <br />Mandell Estate No, 32 <br />May 1, 2004 <br />$688.00 (Due on or before your anniversary date) <br />Baca <br /> <br /> <br />APR 15 2~~ <br />Division of Mineral/$ ®@®~®gr <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 <br />_.~_operator_shall-suhmit~annual~ee,.a~e~ort and_r1~ap showing the extent of current disturbances to affected __ <br />land, reclamation accomplished to date and during the preceding yeaz, new disturbances that are anticipated to <br />occur during the upcoming yeaz, 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 attarh ynnr revised written anmral report and annual re nrt m P to this form. Please note [hat 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 permittee contact information. Please verify and make any necessary <br />changes: <br />PermitteeContact: Ray Miller <br />Pennittee Name: Baca County <br />Address: 741 Main St. <br />Springfield, CO 81073 <br />Phone Number: (719) 523-6532 <br />Fax Number: (719) 523-6584 <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 />Si a I ~e of,C(~o rate Officer, Owner, or Designee <br />~ D e <br />MiPERMITNIASTEADOCUMENTS~hf-AF-04 <br />