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<br />PERMTTTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Divisi of Minerals and Geology <br />Medicine Bow - Routt National Forest USDA Forest ~ervtce <br />M-2000-040 <br />State Line Ranch Pit <br />June 23, 2002 <br />$281.00 (Due on or before your anniversary date) <br />Jackson <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversazy date of the permit, an <br />-operator shall submit the annual-fee, areport-and-map showing the_extent of current 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 the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour revised written annual reuorl and annual resort map 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: CF.PR/.contact first nam/e~CF.PR.contact last name <br />S'T~~er E C"ova / - - <br />Permlttee Name: Medicine Bow - Routt National Forest USDA Forest Service <br />Address: <br />Phone Number: <br />Fax Number: <br />Medicine Bow - Routt National Forest <br />2468 Jackson St. <br />Wyoming, CO 82070-6535 <br />(307)745-2398 <br />3v7 -7y-S - Z~3Z <br />If you have additional comments and/or information that should be provided to the Division, please provide i[ <br />below or attach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />L. <br />Sig tore of Corporate Of tcer or Owner <br />/~sr/5 >~~r4n s4er ~i. T•.-. ~n~j i..ipPrin~ r0~/"~.^ ~n~st ~r e~~ <br />RECEIVED <br />ANNUAL FEE and REPORT REQUEST JUN 0 6 1002 <br />M:~PERMI'rN1ASTERD000MENTSVN-AF-04 <br />