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C. <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Rio Blanco County <br />M-1995-046 <br />Johnson Draw <br />October 7, 2003 <br />RECEIVE® <br />OCT 9 62003 <br />Division of Minerals and GeoloAY <br />$688.00 (Due on or before your anniversary date) <br />Rio Blanco <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 />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 annual rennrt and annnal refit m ~n 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: Jerry Steele <br />Permittee Name: Rio Blanco County <br />Address: 570 2nd St. <br /> Meeker, CO 81641 <br />Phone Number: (970) 878-5601 <br />Fax Number: (970) 878-3396 <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 />Signatu • o Corp ate f icer, Owner, or Designee <br />9-z~-v3 <br />Date <br />M:\PERMITUTASTERDOCUMENTSUI-AF-04 <br />