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-r9 <br />Rff"s, . _~. <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Dolores County <br />M-1995-010 <br />Black Snag <br />March 24, 2004 <br />FEB 2 0 2004 <br />Division of Minerals & Ce01o0Y <br />$281.00 (Due on or before your anniversary date) <br />Dolores <br />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 <br />operator shall submit the_annual.fee._asepoi3_aud_map showing_the_extenLof_cucrent dishnbances to affected - - <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach vrmrr revised written annual rennrt and anmral re on rt ma=n, to this form- please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: <br />Permittee Name: <br />Address: <br />Tim Huskey <br />Dolores County <br />P. O. Box 608 <br />Dove Creek, CO 81324 <br />Phone Number: (970) 677-2328 <br />Fax Number: {970) 677-3759 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />Si nature of Corporate Office ~ caner, or Designee <br />~a - ~i- oy <br />Date <br />M:IPERMI71MAS7ERD000MEN'1'S~h1-AF-04 <br />