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r~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Todd K. Dysart <br />M-2000-149 <br />Todd Dysart Pit <br />January 5, 2004 <br />SAM 0 2 2004 <br />Division of Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Logan <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 operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />--.~-'~-~,~,-n~cemplished-te-date-and-during-the-preceding year,-nevi-disturbances-that-are-anhicipated-to-occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach ^nur revised written anneal reP,nrt and anneal rennrt manrtn this form- Please note that an <br />adequately labeled map that clearly delineates and includes fhe above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Todd K. Dysart <br />Permittee Name: Todd K. Dysart <br />Address: 11481 CR 370 <br />Sterling, CO 80751 <br />Phone Number: (970) 522-8814 <br />Fax Number: <br />If you have additional comments and/or information that should be provided to the Division, please provide <br />below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />i[ c~Jx vC~~o <br />Signature of Corporate Offi r, Owner, or Designee <br />~ a1 V.~n ° ©.~ <br />Date <br />M: W ERMITIMASTERDOCUMENTSVvt-AF-01 <br />5~ <br />S' ~° <br />` ~ ~s~ <br />~µl ~/('~''~ <br />N+~ <br />