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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Glenn Southwick <br />M-1986-007 <br />Masonville Stone <br />March 11, 2003 Division of Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Latimer <br />RECEIVED <br />MAR 0 3 2003 <br />Qrrnrdin~a rn (' R 4 't4-32 5-116 or C R S 34-32-116 each year, on the anniversary date of the permit, an operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to a ecte iah~; <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the 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 the year, if any. <br />Please attach ~nnr revised written anm~al rennet and anneal tenor[ m~ to this form. Please note Yhat an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Glenn Southwick <br />Permittee Name: Glenn Southwick <br />Address:-- . - -220 W-CR 84---- -_ - <br />P.O. Box 1103 <br />Wellington, CO 80549 <br />- ----Phone Number: (970) 568-3579 <br />Fax Number: (970) 568-0602 <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 enclosed. <br />~,~ il.. <br />Signature of Corporate Officer, Owner, or Designee <br />~-~~-v3 <br />Date <br />M:~PERMITMASTERD000MEMSVN-AF-01 <br />