REP42181

• Permit No: M1982044
• IBM Index Class Name: Report
• Doc Date: 4/20/2004
• Doc Name: 2004 Annual Report
• From: Jerry Johnston
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
/\~
Jerry Johnston ~~ (~, ~~ -
~~ ~.1~
M-1982-044 APR
Glen Johnston Site 1 2 Q ~_
- - "" - - - - 6ivision a! Mineral
April 23, 2004 sanaCealogy
$281.00 (Due on or before your anniversary date)
Teller
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 your revised written annnal red nrt and annnal rennrt man M this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may since for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Jerry Johnston
Permittee Name: Jerry Johnston
Address: 13800 Hwy. 24
Divide, CO 80814
Phone Number: [phone]
T, Fax Number___, _ ____, :.___ ~ _
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.
Si lure o orpo to Officer, Owner, or Designee
Date