REP41586

• Permit No: M1987020
• IBM Index Class Name: Report
• Doc Date: 4/19/2004
• Doc Name: 2004 Annual Report
• From: Rio Grande County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

I`.
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Rio Grande County
M-1987-020
374 Pit
Apri123, 2004

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$688.00 (Due on or before your anniversary date)
Rio Grande
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 shall submit the annual fee, a report and map showing the extent of current disturbances to affected
land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to
occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach ym~r revised written anneal report and anneal report map to this form. Please note that an
adequately labeled map that clearly delineates and includes the above etements may since for a written
report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Lawrence "Buddy" Shaver
Permittee Name: Rio Grande County
Address: 168 N. Washington
P.O. Box 46
Monte Vista, CO 81144
Phone Number: [phone]
Fax Number: [phone]
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are
enclosed.
Signature of Corporate Officer, Owner, or Designee
~/ ~~-~ ~
Dale
M:~PERMIT~MASTERDOCUMENTSU~f-AF-04