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- brn~~ <br />'10-3/ oS <br />~~ <br />~~M~ <br />ANNiiAi, FF.F, and RF.PnRT RF.OTiF.ST <br />PERMITTEE NAME: Bent County ,~ <br />PERMIT NO.: M-1983-177 1/ <br />OPERATION NAME: Adams Pit <br />ANNIVERSARY DATE: November 2, 2005 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Bent <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 />operator shall submit the annual.~ee, a-report and map showing the extent of current disturbances to affected , <br />~a'r;~:sri_:)~tat3e?t-ascempGshed.Yo-date-and-duang-the-preceding-.year,-new disturbances-thata~-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' nor revised written annnal rennet and annnal reran m ~n to thls form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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: Gary Pritchard <br />Permittee Name: <br />Bent County <br />Address: <br />P.O. Box 350 <br />Las Animas, CO 81054 <br />Phone Number: (719) 456-2223 <br />Fax Number: - (719) 456-0375 <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 />Signatur f Corporate Officer, Owner, or Designee <br />OCR-oBER ~t X005 <br />Date <br />MdPERM[TNiAS7ERD0 W MEMSNI-AF-04 <br /> <br />