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Il~p,17h11 <br />I'IiRMI'I' NU,: <br />[)1'IfRA IIUN NAMIi: <br />ANNIVIiRtiAKI' I)All <br />ANNI!rV. PP.I~. Ul1F.: <br />CY)l!NTY': <br />A\\L_U. FI•:F' and RF 1'OIYI' RM:U('l• 1'I' <br />Park ('ounh <br />\1- 1980-111'1 <br />Ilall Gulch 1'it <br />\pril I. 1(1116 <br />S28I.ob (Uue on or before your anniversary date) <br />Park <br />Aceurdmg 6> l'.kS. 14-t2,5-1 16 or ('.k.ti. 34-32-116, each year, nn the annnrrsary date of the pcrn,it, an <br />uprnuor shall submit the annual fce, a report and map showing the extent ol• cumnt dlsturbunces to altcctal <br />I:md, reclumution uccontpiished kl date and during ihr preceding year, new di,lurbances Ihat arc ^nticip;dcd at <br />occur durn,g the upcoming year, reclamation that sill be perti,rnted during the cunung year, the dates li,r the <br />hegmnmg of active operuhons, and the date aetlve operuhons tensed I'or the year, If any. <br />I'Iense attach your res fixed written annual rclntrt au 1 annual r •w,rt nmlr t„ this form. I'Inur roar 7hdt rut <br />«r/rq««lrlt lahrlrrl nr«Ir rll;u rlrurl: Jcliruvrn•,~ urrrl rnriudre t4<• uhm'r rlrnrrnt.r non' ,ullirr /nr a ur•iltcu <br />n'141IV <br />I)tvision records indicate the tbllowing permittee comact information. I'Irase verify and make any necessary <br />changes: <br />Permittec ('antuct: David Kintz <br />I'ermittec Name: Park County <br />Address: P.O. Box 147 <br />I'avplay, (•O 811.1-ill <br />Phone Numher: 1719) 836-82t~ <br />Pax Numlxr: 1?19) 816-1275 <br />/i~., Lion/ <br />4~E~3 <br />If you hove atlditinnal camn,cnts anc4'or mtin'nwUon that should be provided U, the Ihvtslott, please provtdc n <br />helow ur attach it to this limn along with your written relwrt and map. Annual Report mstruclions arc <br />endo+cd. <br />-Zr-r.~. <br />Stgnatur~fl't poratc (lfticer, (hence, or I)cslgnce <br />' ~-17-DG <br />I):nc <br />M.,PFNMI raM Ati I f' P Ix x'1: M1tF.4'i tiAl• AF~ W <br />