2006-10-04_REPORT - M1991080 - Laserfiche WebLink

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~1~- b wl l~- PERMITTEE NAME: PERMIT NO.: OPERATION NAME: ANNIVERSARY DATE: ANNUAL FEE DUE: COUNTY: y Russ Vau Egmoud ~ M-1991-080 y Stones Ranch Grav Pt October 25, 2006 $281.00 (Due on or before your anniversary date) Teller R~~Fw~FD ~ OCT 0 4 2006 Div n ~9fe^d Safety ^ 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 V during the upcoming year; reclamation rFia~ will~fie perl- orme3 during the coming year, the Gate is or rie-begmning of active operations, and the date active operations ceased for the year, if any. Please attach vour revised written annual resort and annual report man to this form. The Annual Report & Fee requirement is not met until we have received the following components: fee, report, and associated map. If no new disturbances or reclamation have occurred durinc the previous vear and no new chances to the previous year's map are necessary, then no new map is required, provided that the Operator shall state this in the Annual Reuort. Please note that an adequately labeled map that clearly delineates and includes the above elements may since for a written report. Division records indicate the following permittee contact information. Please verify and make any necessary changes: Permittee Contact: Russ Van Egmond Permittee Name: Russ Van Egmond Address: 546 Doe Valley Rd. Guffey, CO 80820 Phone Number: (719) 689-0877 Fax Number: 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. ~F71.~i~ Q1~.t.~_ 2 a tgnature of Corporate Officer, Owner, or Designee ~!. Date