REP44156

• Permit No: M1983050
• IBM Index Class Name: Report
• Doc Date: 3/15/2004
• Doc Name: Annual Fee/Report Notice
• From: Phillips County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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RECEIVED
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COi-JN"I'Y:
Phillips County
M-1983-050
State Land-Jensen Pit
Apri128, 2004
MAR 15 2004
Division of Mineralslatiealagy
$281.00 (Due on or before your anniversary date)
Sedgwick
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 mag 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 ynnr revised written annual report and anmral report m}ip fn this form. Please note that an
adequately labeled map that clearly dedineates and includes the above elements may since far a written
report.
Division records indicate the following petmittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Randy Schafer
Permittee Name:
Address:
Phillips County
221 S.Interocean
Holyoke, CO 80734
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.
~lt~l S~/!'~Y1 o~LP~1/
Signatu of Corpor e Officer, Owner, or Designee
~/e/oy
Date
M:~PERMITUTASTERDOCUMENTSU-I-AF-04