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~- <br />..- <br />(/ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Park County <br />M-1977-365 <br />Sulphur Mtn Grav Pit <br />April 1, 2003 <br />RECEIVED <br />APR 0 9 2003 <br />Division aI Minerals and GeolO~Y <br />$281.00 (Due on or before your anniversary date) <br />Park <br />____ __According_to_C.R.S. 34-32.5-L16-or C.R.-S-34-32-1-16; each-year,-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 y nor revised written annual rennrt and anm~al report marn to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice 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 <br />Permittee Name: Park County <br />Address: P.O. Box 147 <br />Fairplay, CO 80440 <br />Phone Number: (719) 836-4270 <br />Fax Number: (719) 836-4275 <br />If you have additional comments and/or information that should be provided to [he 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 />~~ <br />Officer, Owner, or Designee <br />Date <br />M1PERMITMASTERD000MENTSVN-AF-04 <br />