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~~ ! L_,.J <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />Moffat County <br />M-1978-007 <br />Big Burn Pit No 17 <br />February 23,2005 <br />$688.00 (Due on or before your anniversary date) <br />Moffat <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 />____ -land,-reclamation-accomplished to_date_and_duringlhe,preceding yearrnew-dishirbances-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 ynnr revised written gnnnal re~7nrt and annnal report mar to Chic form- Please note [hat an <br />adequately labeled map that clearly delineates and includes the above elements may suffice 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: Billy E. Mack <br />Permittee Name: Moffat County <br />Address: P.O. Box 667 <br />Phone Number: <br />Fax Number: - <br />Craig, CO 81626 <br />(970)824-3211 <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 />STOCKPILE REDUCTION - NO MAP NECESSARY. <br />1 ~ ~~ ~ <br />Signatur Corporate Officer, Owner, or Designee <br />1~ ie-~~; <br />Dale <br />M:~PERMIriMASTERDOCUMEMS4M-AF-04 <br />