|
RECEI!/ED
<br />ANNUAL FEE and REPORT REQUEST
<br />APR 2 3 2002
<br />Division of Minerals and Geology
<br />PERMITTEE NAME:
<br />PERMIT NO.:
<br />OPERATION NAME:
<br />ANNIVERSARY DATE
<br />ANNUAL FEE DUE:
<br />COUNTY:
<br />Clyde and Marie Couch
<br />M-1989-023
<br />Caliche School Pit
<br />March 9, 2002
<br />$281.00 (Due on or before your anniversary date}
<br />Logan
<br />According to C.R.S. 34-32.5-I 16 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an operator
<br />shall submit [he annual fee, a report and map showing the extent of current disturbances [o affected land,
<br />....,.u ........... ...........Y...,..,,...., ..,... ,.......,.....b ...., Y..,.,......b ~.,~., ...,.....,.~.,,,..... , ..,.., u.., .....,,,Y,..,,,, .., ,,..,..
<br />during [he 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 [he year, if any.
<br />Please attach vour revised written annual report and annual report map to this form. Please note that an
<br />adequately labeled wrap that clearly delineates and includes the above elements may since for a written report.
<br />Division records indicate the following permittee contact information. Please verify and make any necessary
<br />changes: `
<br />Permittee Contact: Clyde Couch
<br />Permittee Name: Clyde and Marie Couch
<br />Address: 1-995 =~td~k ~&-
<br />la >~ -
<br />Sterling, CO 80751
<br />Phone Number: (970) 522-1239
<br />~nr~ U1~~ Sv ~ `T!'l~~ l~rn aln9P~
<br />f7d ~ t7~ ~-c L~ sal- c, c na o~ QQ __
<br />~~, .f „~~~_~_ r~_ k.Fi„s
<br />--- Fax Number: -- - - - -- - - - -- -
<br />If you have additional comments and/or information that should be provided to the Division, please provide it
<br />below or attach i[ to this form along with your written report and map. Annual Report instructions are enclosed.
<br />Signat re of Corpora e Officer or Owner
<br />1 -~/- TT
<br />Date
<br />M:tPERM mMASTERDOCUM ENTSNI-AF-OI
<br />
|