2004-04-13_REPORT - M1986047

• Permit No: M1986047
• IBM Index Class Name: Report
• Doc Date: 4/13/2004
• Doc Name: Annual Fee/Report/Map
• From: Phillips County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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PERMTTTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Phillips County
M-1986-047
Austin Pit /
May 5, 2004
~~~:;

Division of Rtirtarals & GealogY
APR 1 3 2004
$281.00 (Due on or before your anniversary date)
Phillips
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 to affected
- --land,-reclamation-accomplished-to'date-and-during the-preccdingyear,-new'distarbances'that are anticipated'to - -
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.
Ptease attach ymrr revised written anmral rennrt and anmrsl re n,~~ rt man to this form- Please note that an
adequately labeled map that clearly delineates and includes the above elements may suffice for a written
report.
Division records indicate the following permittee contact infom~ation. Please verify and make any necessary
changes:
Pennittee Contact: Randy Schafer
Permittee Name: Phillips County
Address: 221 S. Interocean
Holyoke, CO 80734
Phone Number: [phone]
Fax Number: [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 are
enclosed.
Gs'on,~,~l,~~
Signature of Corpora e Officer, Owner, or Designee
Date
M:SPERM]TYNASTERDOCUMENTS~hI-AF-04