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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Fremont County <br />M-1994-118 <br />Phantom Canyon Pit <br />August 8, 2004 <br />$281.00 (Due on or before your anniversary date) <br />Teller <br /> <br />RECEIVE'® <br />SEP i 5 ?ppq <br />Division oiMinerals and Geology <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 submit the annual fee, a report and map showing the extent of curent 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 tthe <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach ynnr revised written anmral report and anneal re~nH main, 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: ~Q~,/ ~~~ Q~ <br />Permittee Name: Fremont/County <br />Address: <br />Phone Number: <br />Fax Number: <br />County Commissioners <br />615 Macon Ave., Room #100 <br />Canon City, CO 81212 <br />(a't9j'2.7Fi-'F39~ <br />(719)275-7626 <br /> <br />- ~'~--~ ~~..~, ~_r.- <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 />G' °' ° "X <br />Signatur~rateOwner, or Designee <br />g/ 9/a <br />Date <br />M:~PERMITMAS7ERD000MENTSw]-AF-04 <br />