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<br />ANNUAL REPORT <br />. ~ <br />RECF11/gyp <br />PERMTI'TEE 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 />j <br />Division of tdirarais 8 Gec:ogy <br />YCEIVED <br />^^~ ~a:~ <br />'a!- 8 Geology <br />According to C.R.S. 34-32-116(3)(a), each year, on the anniversary date of the permit, 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 dale and during the preceding year, new <br />disturbances that aze anticipated to occur during the upcoming year, reclamation [hat tivill be <br />performed during the coming yeaz, the dates for the beginning of active operations, and [he date <br />active operations ceased for the yeaz, if any. <br />Please attach your revised annual report map and written report to this <br />annual report. Please ,rote that mt aJequatr/n /uhe(er/tnnp Iluu clearh clelineate.e nnrl <br />inchales the aGove elentents ntnv suffice for a written reprn~t. <br />Please type or print the current contact person's name, mailing address, and phone number in Uie <br />space provided: <br />Contact Name;AL J CAMPBELL, PRESIDENT Company: FARMERS STATE BANK OF BRUSH <br />Address: 200 CLAYTON ST P 0 BOR 324 <br />BRUSH, CO 80723-0324 <br />Phone No.: (970 ) 842-5101 <br />Fax No.: (970 ) 542-5105 <br />If there are additional comments and/or information that should be provided to the Division, <br />please provide it on a separate sheet and attach it [o this report form along with your map and/or <br />written report. <br />Signature of tporate Offi er, or Owner Date <br />INSTRUCTIONS ON BACK <br />