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RECEIVED <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Ricky W. Mitchell <br />M-1990-131 <br />Mitchell Pit #2 <br />February 14,2004 <br />FEB 11 2004 <br />Division ~f Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Adams <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 operator <br />shall submit the annual-fee, areport-and-map-showing-the .extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated-to occur -- <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach ynnr revised written annual tenor[ and annual tenor[ main to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: <br />Permittee Name: <br />Address: <br />Ricky W. Mitchell <br />Ricky W. Mitchell <br />P. O. Box 10 <br />Bennett, CO 80102 <br />Phone Number: (303) 644-4102 <br />Fax Number: <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 enclosed. <br />Signature of orate Officer, Owner, or Designee <br />~~/ / boy <br />Date <br />M:~PERMITN7ASTERDOCUMEMS~M-AF-01 <br />