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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Phillips County <br />M-1989-095 <br />Schneller Clay Pit <br />November 27, 2002 <br />RECEIVED <br />ocr 3 o Z~.~z <br />'~y- <br />Division of Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Phillips <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 />__ ___- opera or sbaU~vhtniL[he_atutuaLfee,_a_repoct and_map-showing-the-extent-o_f_eurien[ disturbances-to-affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances 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 your revised written annual report and annual report map to this form. Please note that 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: Randy Schafer <br />Permittee Name: Phillips County <br />Address: 221 S.Interocean <br /> Holyoke, CO 80734 <br />Phone Number: (970) 854-3778 <br />Fax Number: (970) 854-3811 <br />If you have additional comments and/or information that should be provided to [he Division, please provide i[ <br />below or attach it to [his form along with your written report and map. Annual Report instructions are <br />enclosed. <br />Signature Corpo~~ rect Owner, or Designee ~ , <br />/D~Z,~OZ <br />Date <br />M: W EftMI"1 \MASTERDOCUMENTS~h1.AF-P1 <br />