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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Sheldon Gosney <br />M-1977-446 <br />Ignacio Pit <br />December 30, 2003 <br />NOVp~~ <br />Dfbrsibn bf Minerals andGeblogy <br />$688.00 (Due on or before your anniversary date) <br />La Plata <br />According tti 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 />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated 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 y~ngr revised writt n anmral ~~ art and annual re~nrt m ~n to this form. Please note that an <br />adegaately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following perruittee contact information. Please verify and make any necessary <br />changes: <br />Pennittee Contact: Sheldon Gosney <br />Fennittee Name: Sheldon Gosney <br />Address: P.O. Box 1186 <br /> Bay&eld, CO R 1122 <br />Phone Number: (970) RR4-46R4 <br />Fax Number: 9'70 ' s~o 3- 1JoZ. 9q <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 map. Annual Report instructions are enclosed. <br />Signature of Corporate Officer,~Ow e~ esignee <br />Date <br />M17dPCRMi'PMA4CRD0C'UMIiN9 S`M-Ar-01 <br />