REP23488

• Permit No: M1981138
• IBM Index Class Name: Report
• Doc Date: 7/2/2001
• Doc Name: ANNUAL FFEE AND REPORT REQUEST
• Permit Index Doc Type: ANNUAL FEE / REPORT
• Media Type: D
• Archive: No

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ANNUAL FEE and REPORT REQUEST
PERMI7TEE NAME:
PERMTT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Baca County
M-1981-138
Gravel Pit No 17
July 24, 2001
III IIIIIIIIIIIIIIII
999
JUL 0 2 2001
Division of Minerals and GeolagY
$281.00 (Due on or before your anniversary date)
Baca
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 annual fee, a report and map showing the extent of current disturbances to affected
land, reclamation accomplished to date and during the preceding year, new disturbances that are 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.
Please attach your revised written annual report and annual report man to this form. Please note that arr
adequately labeled map that clearly delinentes and includes the above elements may since far a written
report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Ted Lasley
Permittee Name: Baca County
Address: 741 Main St.
Springfield, CO 81073
Phone Number: [phone]
Fax Number: [phone]
If you have additional comments 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. Annual Report instructions are
enclosed.
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Signature of Corpo ate Officer or Owner
Dale
M1f: W ERM R V.7ASTERD000M EfJI'SN7-AF~O!