2006-08-16_REPORT - M1994077

• Permit No: M1994077
• IBM Index Class Name: Report
• Doc Date: 8/16/2006
• Doc Name: Annual Fee/Report/Map
• From: Washington County
• To: DRMS
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
t/ ANNUAL FEE and REPORT REQUEST
~ Washington County
~M-1994-077
Nickell Gravel Pit
August 25, 2006
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ail ~
RECEIVED
~AUG 16 2006
i
Division of Reclamation,
Mining and Safety
$281.00 (Due on or before your anniversary date)
Washington
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
]and, reclamation accomplished to date and during the preceding year, new disturbances that aze anticipated to
occur during the upcoming yeaz, 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 vour revised written annual resort and annual resort mau to 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: Boazd of County Commissioners CF.PR.contact_last_name
Permittee Name:
Address:
Washington County
150 Ash
Akron, CO 80720
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 Co~i`orate Officer; Owner, or Designee
`7S~1~)~~)/
Date
M:IPERMI7IMASTERDOCI7MENTSIM-AF-04