2006-03-10_REPORT - M1983050

• Permit No: M1983050
• IBM Index Class Name: Report
• Doc Date: 3/10/2006
• Doc Name: Annual Fee/Report/Map
• From: Phillips County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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i/ ANNiiAi, FF.F, and RF,PiIRT RF.t1iiF.ST
REC~IV~®
LP1AR 1 i, 2006
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
/ Phillips County
M-1983-050
State Land-Jensen Pit
Apri128, 2006
$281.00 (Due on or before your anniversary date)
Sedgwick
V D'wsion of Minerals and Geology
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
operator-shall-submit-theannual-fee; a-report-and-map-showing-the-extent,of current_dicturbances to affected__ ~_
land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to
occur during the upcoming yeaz, 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 your revised written anneal re~nrt and anneal rennrt map to this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may since for a written
report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Pennittee Contact: Randy Schafer
Permittee Name: Phillips County
Address: 221 S.Interocean
Holyoke, CO 80734
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.
G~~,~~„
Signatur f Corporate fficer, Owner, or Designee
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Date
M:~PERMI7IMASlERI)OCUMENT5NI-AF-04