2003-06-02_REPORT - M2000040

• Permit No: M2000040
• IBM Index Class Name: Report
• Doc Date: 6/2/2003
• Doc Name: Annual Fee/Report/Map
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

J RECEIVED
JUN 0 2 2003
ANNTiAT, FF.F, and RF,PnRT RF.(TTiF.ST Oiuision ~f Minerals and Geolu'y
PERMITTEE NAME: Medicine Bow - Routt National Forest USDA Forest Service
PERMIT NO.: M-2000-040
OPERATION NAME: State Line Ranch Pit
ANNIVERSARY DATE: June 23, 2003
ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date)
COUNTY: Jackson
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; reclamafiori accomplish"ed" to date and-during the preceding year, new disturbances [haY are arincipaied to
occur during the upcoming year, reclamation [hat will be performed during the coming year, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach your revised written anneal re~nrt and annual reFnrt m ~n to this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may suffice for a written
report.
Division records indicate the following permit[ee contact information. Please verify and make any necessary
changes:
Permittee Contact: CF.PR.con[act_/first_name CF.PR.contact_last_name
Permittee Name: Medicine Bow - Routt National Forest USDA Forest Service
Address: Medicine Bow - Routt National Forest
2468 Jackson St.
yomingrCQ820Z0=6535_- _ __
Phone Number:
(~97~~3b0
07) 7M"S- 2y-3'Z
Fax Number:
[phone]
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.
~~~~ ~~~
Signature of Corporate Office ,Owner, or Designee
M:\PERM INNASTERDOCUMENTSVvI-AF-04