2007-05-11_REPORT - M2004023

• Permit No: M2004023
• IBM Index Class Name: Report
• Doc Date: 5/11/2007
• Doc Name: Annual Fee/Report/Map
• From: Phillips County
• To: DRMS
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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ANNUAL FEE and REPORT REQUEST
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Phillips County
~ M-2004-023
Haynes Hereford Ranch Pit
June 2, 2007
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$$281.00 (Due on or before your anniversary date)
Phillips
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 -
bpe~'orsfialf 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 yeaz, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach your revised written annual report and annual report map to this form. The Annual
Report & Fee requirement is not met until we have received the following components: fee, reuort, and
associated map. If no new disturbances or reclamation have occurred durinc the previous year and no
new chances to the previous year's map are necessary, then no new mau is required, provided that the
Ouerator shall state this in the Annual Report. Please note that an adequately labeled map that clearly
delineates and includes the above elements may suffcce for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact:
Permittee Name:
Address:
Phone Number:
Fax Number:
Randy Schafer
Phillips County
221 S.Interocean Ave.
Holyoke, CO 80734
[phone]
[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 aze
enclosed.
Signature yffjCorporate Offigkr, Owner, or Designee
Date
M:~PERMITVAASTERD000MENTSNI-AF-04