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1r/ <br />ANNIIAi. FF.F. and REPORT RF.(NTF.ST <br />RE~;Iti`~~® <br />PERMITTEE NAME: Park County <br />APR 2 ~ ~ <br />PERMIT NO.: M-1995-027 <br />Division of Minerals and Gealegy <br />OPERATION NAME: Ansley Pft No 2 <br />ANNIVERSARY DATE; May 8, 2004 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Park <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'shatl submit-the-annual-fee, a report and-map showittg-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 Ymrr revised written anmral re,~tnrt and annual re~,nrnrt m 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 permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Doug Keith ~ o b er 1` ~ c e. <br />Permittee Name: Park County ~e ~ k Cam,. ~~ <br />Address: P. O. Box 147 <br />Fairplay, CO 80440 <br />Phone Number: (719) 836-4270 ~7 ~ 5) Sr3~- YZ £sZ <br />Fax Number: (719) 836-4275 <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 />-rY !~ ~- <br />Si afore of Corporate Officer, Owner, or Designee <br />y~ 9~D ~/ <br />Dae <br />M;~PERMIIIMAS7ERDOCUMENTSNr-AF-09 <br />