2006-03-10_REPORT - M1984185

• Permit No: M1984185
• IBM Index Class Name: Report
• Doc Date: 3/10/2006
• Doc Name: Annual Fee/Report/Map
• From: Lincoln County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

MRR-10,2006 11:16 FROM:COUNTY RpMINISTRRTOR 719 743 2815 TD:[phone]
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A1V1NIrAi, t7Ti.F. gnd RFTnRT RF.Ai1<i:ST
PER&II1Tl3E NAME: ~ Lincoln County
PERMIT NO.: ;~ M-1984-185
OPE1tATtON NAME: Ellis AUon Ylt
ANNIVERSARY RATE; February 2S, 2006
ANNUAL FEE DUE: $251.00 (Dne on or before your amai{verssry date)
COUNTY: Y.ineoln
P.3~5
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 atmual fee, a report and map showing the exmnt of ciare~at disturbanecs to affected
land, mcla~tion accomplished to date and during the preceding year, new dishrrbaaces that ere anticipated to
occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Pieese attach yynr revised wrtttan gpJ~,~ art amdannnol report m to this inrm_ ple0.te note drat an
adequately labeled map that dearly delineates and includes the above elements may sgBSce jot a wrinen
report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Don Blake
Petmittee Name: Lincoln County
Address:
Phone Number:
P.O. Box 39
Hugo, CO 80821
[phone]
Fan Number: [phone]
if you have additional comuneots and/or information that should be provided to the Division, please provide it
below. or attach it to this form along with, your written report and map. Affiual Report inatructioms am
enclosed.
SignatutE of Corporate Officer, Owner, of Designee
ar-a~6- D L. _
Date