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<br />l~ <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-1978-080 <br />Elmer Stone Gravel Pit <br />May 24, 2002 <br />RECEA~.~Ep <br />APlZ 1 1 ~^~? <br />Division of Minerals and CeologY <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_curtentdisturbances 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 yeaz, if any. <br />Please attach vour revised written annual report and annual report map to this form. Please note that an <br />adegaately 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: <br />Permittee Name: <br />Address <br />Phone Number: <br />Fax Number: <br />Don Blake <br />Lincoln County <br />P.O. Box 39 <br />Hugo, CO 80821 <br />(7]9)743-2337 <br />(719)743-2815 <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 />Signature of Corporate Officer or Owner <br />p~[ ~o~{ ~ ~2- <br />Date <br />M:~PERM17 VNASTERDOCUMENTSVvi-AF-6A <br />