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~ • III 1111111111111111 <br />999 <br />ANNUAL REPORT <br />PERb11TTEE NAME: Farmers Bank of Brush <br />PERMIT NO.: M-80-135 <br />OPERATION NAME: Headley Farms <br />ANNNERSARY DATE: October 07, 1999 <br />ANNUAL FEE DUE ON ANNIVERSARY DATE: $550.00 <br />COUNTY: Morgan <br />pECEI~rGr <br />FEg `~, 5 2000 <br />Division of Mtnerars ~ beoio9Y <br />According to C.R.S. 3d-32-1 l6(3)(a), each year, on the anniversary date of the petTttit, an <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances <br />to affected land, reclamation accomplished to date and during the preceding year, new <br />disturbances that are anticipated to occur during the upcoming year, reclamation that will be <br />performed during the coming year, the dates for the beginning of active operations, and the date <br />active operations ceased for the year, if any. <br />Please attach vour revised annual report map and written report to this <br />annual report. Pleusr Write rl+crr rr'rr «rlc~gtrrrtr/~ lahr/rd nw/+ that clenr!_r d~-line-utec and <br />includes r/re abate e/en+enrs nary since for a wrruen report. <br />Please type or print the current contact person's name, mailing address, and phone number in the <br />space provided: <br />Contact Name: AL J CAPfPBELL, PRESIDENT <br />Address: 200 CLAYTON ST P 0 BO;: 324 <br />BRUSH, CO 80723-0324 <br />Company: FARMERS STATE BANK OF BRUSH <br />Phone No.: (970 ) B42-5101 <br />Fax No.: (970 ) 842-5105 <br />If there are additional comments and/or information that should be provided to the Division, <br />please provide it on a sepazate sheet and attach it to this report form along with your map and/or <br />written report. <br />~.. ~ A~J "` ! O O <br />~"ignature otporate Of tce , or Owner Date <br />INSTRUCTIONS ON BACK <br />ORIGINAL SENT AND FEE S~JBMITT~D SEPTEMBER 28 1999 <br />