Laserfiche WebLink
ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME; <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE; <br />COUNTY: <br />Jerry Johnston <br />M-1982-044 <br />Glen Johnston Site 1 <br />April 23, 2006 <br />$281.00 (Due on or before your anniversary date) <br />Teller <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 current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that aze anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming yeaz, the dates for the <br />beginning of active operations, and the date active operatons ceased for the yeaz, if any. <br />Please attach your revised written annual report and annual report map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following pennittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Jerry Johnston <br />Permittee Name: Jerry Johnston <br />Address: 13800 Hwy. 24 <br />Phone Number: <br />Fax Number: <br />Divide, CO 80814 <br />(719)687-9043 <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 enclosed. <br />Signature of Corporate Officer or Owner <br />Date <br />