REP16130

• Permit No: M1999024
• IBM Index Class Name: Report
• Doc Date: 10/12/2004
• Doc Name: Annual Report and Fee
• From: Costilla County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Costilla County
M-1999-024
San Acacio Gravel Pit
October 4, 2004
REC~~V~~
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Division of Minerals and GeoloBY
$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 and map showing the extent of current disturbances 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 year, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach ym~r revised written anm~al rennrt and annual rennrt m~ 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 information. Please verify and make any necessary
changes:
Permittee Contact: Mathew L. Valdez
Permittee Name:
Address:
Costilla County
352 Main St.
San Luis, CO 81152
Phone 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. Annua] Report instructions are
enclosed.
~r' (GZt~/LUa~
Signature o//f Corporate Officer, Owner, esignee
Date
M:~PERMITN.fASTERDOCUMENTSVd-AF-04