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~r y <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 />Montezuma County <br />M-1985-172 <br />Gardner Pit <br />November 25, 2002 <br />RECEIVECD <br />ocr z ~ 2~2 <br />Division ~f Minerals and Geology <br />$688.00 (Due on or before your anniversary date) <br />Montezuma <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 cuttent disturbances [o affected <br />land, reclamation accomplished to date and during [he"preceding year, new disturbances [hat are anticipated to <br />occur during [he upcoming year, reclamation that will be performed during [he coming year, the dates for [he <br />beginning of active operations, and [he date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual report mau to this form. Please note that an <br />adequately labeled map that clearly delineates atul 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: Lloyd Everett <br />Permit[ee Name: Montezuma County <br />Address: 1680 Hwy. 145 <br />Phone Number: <br />Fax Number: <br />Cortez, CO 81321 <br />(970)565-8666 <br />(970)565-8252 <br /> <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 />S gnature o Corporate Officer, Owner, or Designee <br />to/~/o~ <br />Date <br />M:~PERMITMASTERD000MENTSVN-AF-06 - <br />