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(r'iP S <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Wagner Construction, Inc. <br />M-1999-018 <br />Wagner Rock <br />April 2Q, 2004 <br />~"AR 2 5 200 <br />D"'~ ~ •° -< dAinerals and GeolollY <br />$281.00 (Due on or before your anniversary date) <br />Moffat <br />According to C.R.S. 3_4--32.5-116. or C.R.S..34_32-116, each year, on the anniversary date ofthe-permit, an operator <br />shall submit the annual fee, a report 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 Km~r revised written annnal rennH and annnal reunrt map to Chic form Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Jay L. Wagner <br />Permittee Name: Wagner Construction, Inc. <br />Address: 96400 E. Hwy. 40 <br />Craig, CO 81625 <br />Phone Number: <br />Fax Number: <br />(970)824-2709 <br />(970)824-2709 <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 />~- <br />ofCorporate ffic ,Owner, or Designee <br />,i~~ <br />Dale <br />