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I i H Y. +. <br /> <br /> <br />RFCElV~ED <br />PERMffTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Washington County <br />M-1983-001 <br />Cecil 11-34-49 <br />May 16, 2004 <br />$281.00 (Due on or before your anniversary date) <br />Washington <br />MAY 0 8 2004 <br />Ofuision of Minerals t'v Ceolopy <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, a report and map showing the extent of current disturbances to affected <br />-r- land; reclamation-accomplished-to-date-and during-the-preceding-year, new.disturbances-thatare-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 ynnr revised written anmial rennrt and annual re~nrt mgt to thic 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: Larry Champ <br />Permittee Name: Washington County <br />Address: 150 Ash <br />Akron, CO 80720 <br />Phone Number: (970) 345-2701 <br />Fax Number: (970) 345-2702 <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 />~'Ignat~t re of~c~rporate Off er, Owner, or Designee <br />_____t~ - y-~ <br />Date <br />M:~PERMITVNASTERDOCUMENTS~M-AF-09 <br />