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t .. <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Lincoln County <br />M-1987-016 <br />County Line Pit <br />Apri17, 2002 <br />`~ <br />RECEIVED <br />MAR07~ <br />~inistOp rif Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Lincoln <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 during the preceding year,-new disturbances that are anticipated to- ---- <br />occur during the upcoming year, reclamation [hat 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 vour 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 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: Don Blake <br />Permittee Name: Lincoln County <br />Address <br />Phone Number: <br />Fax Number: <br />P.O. Box 39 <br />Hugo, CO 80821 <br />(719)743-2337 <br />(719)743-2838 <br />If you have additional comments and/or information that should be provided to the Division, please provide i[ <br />below or attach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />Signature of Co//porate Officer or Owner <br />D,~~~O ~~ /d Z <br />Dale <br />M:~PERMI"tN~iASTERDOCUMENTSVN-AF-04 <br />