2005-08-17_REPORT - M1978266

• Permit No: M1978266
• IBM Index Class Name: Report
• Doc Date: 8/17/2005
• Doc Name: Annual Fee/Report/Map
• From: Jackson County
• To: DMG
• Media Type: D
• Archive: No

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
ackson County
~M-1978-266
Riley Gravel Pit
August 15, 2005
mot, ~UG 17 2005
'' V division u9 P.:,..~~-~~~ r~~ ''-oloAtl
$688.00 (Due on or before your anniversary date)
Jackson
According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an
operator shall submit the annual fee, areport-and map showing the extent of current disturbances to affected
land, reclamation accomplished to date and during the preceding year, ne~v disturbances that are anticipated to
occur during the upcoming year, reclamation that will be perforated during the coming year, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach ynnr revised written annual red nrf and anm~al re, nrt man to thic form- Please note that an
adequately labeled map that clearly delineates and includes the above elements may since for a written
report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Nelson Selcer
Permittee Name:
Address:
Phone Number:
Fax Number:
Jackson County
P.O. Box 488
188 Grant Street
Walden, CO 80480
[phone]
[phone]
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are
enclosed.
~_~
Signature o Corporate Officer, Owner, or Designee
'1- ~~ -a~
Date
~ L
M:IPERMITN1ASiERD000MEM$UvI-AF-04