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ANNrIAi. FF.F. and RF.P(1RT RF.niTF.ST RECEIVE® <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Lincoln County <br />M-2004-001 <br />Lofdahl <br />February 13,2005 <br />FEB 0 t 2005 <br />Division of Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Lincoln <br />A-JW <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 fee, a report and map showing the extent of current disturbances to affected <br />`land-reclamation-accomplished-to•date-and-during-the-preceding-year,-nevi-disturbances-that are.anticipatedto <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 Ynnr revised written anmral rennrt and anmial rennrt m~ to this form. j~[ease note that aK <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: Don Blake <br />Permittee Name: Lincoln County <br />Address: P.O. Box 39 <br />Phone Number: <br />Fax Number: <br />Hugo, CO 80821 <br />(719) 743-2337 <br />(719) 743-2815 <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 />7~-~6~^- ~151~ <br />Signature of Corporate Officer, Owner, or Designee <br />O/- off- t]S <br />Date <br />M:~PERMITMASTERD000MEMSNI-AF-04 <br />