2005-07-27_REPORT - M2004037

• Permit No: M2004037
• IBM Index Class Name: Report
• Doc Date: 7/27/2005
• Doc Name: Annual Fee/Report/Map
• From: john m everitt
• To: dmg
• Media Type: D
• Archive: No

~~
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
ANNilAi. FF.F, and RF.P(1RT RE iiF,ST
John M. Everitt ~Tv ~~~
/1Ci-2004-037
Everitt Pit
August 3, 2005
$281.00 (Due on or before your anniversary date)
Phillips
RECE9~fE®
,~11 `1UL 2 71005
~U Division of Minerals end Geology
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
aperator_shalLsubmit the annual fee,_a report and map showing the extent of current disturbances to affected
land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to
occur during the upcoming year, reclamation that 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 ymrr revised written anmral rennrt and anneal rep rt m n 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 permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: John M. Everitt c~(~ 6'K ~
Permittee Name: John M. Everitt ,Jc~ i .w "C.-
Address: 24274 CR 17 .~c~ !2z v
Haxtun, CO 80731 Sc~ vim ~
Phone Number: [phone] cJ G.~'n Z-
Fax Number
If you have additional comments andfor 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.
~'/~
Si re of Corporate Officer, Owner, or Designee
~'Z y -0 ~
Date
M:~PERMIT4MASTERD000MENTSNr-AF-04