2002-12-11_REPORT - M1980233

• Permit No: M1980233
• IBM Index Class Name: Report
• Doc Date: 12/11/2002
• Doc Name: Annual Fee/Report Notice
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
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
fend;-reefamafian-aeearnp3isired-ta-datcand-duringthe-p r, '~ a~ are annctpa e o
occur during the upcoming year, reclamation that will be performed during the coming year, [he dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach vour revised written annual report and annual report map to this form. Please trote that an
adequately labeled map that clearly delineates curd 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: Elizabeth Pacheco
Permittee Name:
Address:
ANNUAL FEE and REPORT REQUEST
Costilla County
M-1980-233
Costilla
December 11, 2002
RECEIVED
DEC ' 1 ^`~JZ
Division of Minerals and Geology
$251.00 (Due on or before your anniversary date)
Costilla
Costilla County
P.O. Box 100
San Luis, CO 81152
Phone Number: [phone]
Fax Number:
e05Yt1~1-.A CoUn~TX
(J. O . talO X 17 b
5t9N h~~s Co sltsz,

If you have additional comments and/or information that should be provided to [he Division, please provide i[
below or attach it to this form along with your written report and map. Annual Report instructions are
enclosed.
Signature of Corporate Officer, Own , or Designee
iz~~lDZ,
Date
M:~PERMITMASTERD000MENTSVN-AF-04