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~iECE1VE[~ <br />(,~ OEC 162005 <br />6irisian of 16iaerals aad ~8Y <br />PERMITTEE NAME: <br />PERMff NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />Rio Blanco County <br />M-2004-038 <br />West Johnson Draw <br />January 7, 20D6 <br />$281.00 (Dae on or before your anniversary date) <br />Rio Blanco <br /> <br />N <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the pemtit, an <br />- opentorshali-submit-the armual fee, a report and-map showing the extrnt ofcurreardisturbances-to affected - - <br />land, reclamation accomplished to date and during the preceding yeaz, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming yeaz, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach ynnr revised written annual reo~rt and annual rennrt mylp to his fnrm_ PI¢AS2 note fNQ! On <br />adequately labeled map Ghat clearly delineates and includes the above elements may suffice jar a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Staalsy-Rasmussen <br />~' Permittee Name: Rio Blanco County <br />/~ Address: 1.2493-Cb^3i'i'fvt <br />Rangely; 26-8tS4S~ <br />Phone Number: l'~ <br />Fax Number: ~!Z76)-6~5$i'I <br />~D n ~ 2~¢~?2Y <br /> <br />q ~o - 578- q5q o <br />970 - Ff 7g - .33`t to <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 rnap. Annual Report instructions are <br />enclosed. <br />Rb.,~ h <br />Signature of Corporate fficer, Owner, or Designee <br />l,'z. - to - o s <br />Date <br />M:~PERMI'MrASTERD000MEN7STI-AF-0i <br />b'd 9498-SL9-OL6 dSE=EO SO SO oa0 <br />