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N/ <br />%~~ ANNTTAT, FF.F, and REPt7RT RF.QTTFST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Fred and Betty Holley <br />M-1977-293 <br />Monogram-Jo Dandy <br />November 27, 2004 <br />$225.00 (Due on or before your anniversary date) <br />Montrose <br /> <br />u~J'~ 2 i ~~~,... <br />r L~~~ <br />~~irisian et Rline~als ~, C~In.V <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 />~ope~tor 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 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 ynnr revised written anneal report and annual r~nrt 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: Fred Holley <br />Permittee Name: Fred and Betty Holley <br />Address: P.O. Box 162 <br />Dove Creek, CO 81324 <br />Phone Number: (970} 677-4158 <br />Fax Number: <br />1 ~ Vl C~~1QV1~ <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 oepor .Officer, Owner, or Designee <br />Date <br />~J <br />M:~PERMI'1lMASTERDOCUMENTS/M-AF-02.DOC <br />