REP13533

• Permit No: M1994103
• IBM Index Class Name: Report
• Doc Date: 6/10/2002
• Doc Name: 20025 Annual Report
• From: Costilla County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

RECEIVE®
PERM11"I'EE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
ANNUAL FEE and REPORT REQUEST
Costilla County
M-1994-103
Sierra Grande Site
June 6, 2002
JUN 1 0 2002
Division of Minerals and Geology
$281,00 (Due on or before your anniversary date)
Costilla
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 aid map`showing the extent'of current'dis[urbances'to-affected
land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to
occur during the upcoming year, reclamation that will be performed during the coming yeaz, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach your revised written annual resort and annual report map to this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may suffice for a written
repon.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Elizabeth Pacheco
Permittee Name:
Address:
Costilla County
P.O. Box ]00
San Luis, CO 8] 152
Phone Number: [phone]
Fax Number: [phone]
If you have additional comments and/or information that should be provided [o the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions aze
enclosed.
Y~~ / l
lSrg ture of~Corporate fficer or Owner
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