2004-10-21_REPORT - M1996073

• Permit No: M1996073
• IBM Index Class Name: Report
• Doc Date: 10/21/2004
• Doc Name: Annual Fee/Report/Map
• From: Sedgwick County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Sedgwick County
M-1996-073
Dolezal Gravel Pit
November 8, 2004
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Division of Mineral;; & Geology
$281.00 (Due on or before your anniversary date)
Sedgwick
_ According to .C.R.S. 34-32.5.116 _or_C.R,S., 3432_116,-each_year-on_the anniversary-date-of the permit, an
operator shall submit 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~ur revised written annual report and anm~al re~nrt main to this form- please note that an
adequately labeled map that clearly delinentes 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:
Pennittee Name:
Address:
Randy Renquist
Sedgwick County
223 S. Cedar
Julesburg, CO 80737
Phone Number: [phone]
Fax Number: [phone]
If you have additional comments and/or 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.
gnature of Corporate Officer, Owner, or Designee
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Date
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