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<br />R~~~:, .. <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Lincoln County <br />M-2002-017 <br />O'Dwyer <br />March 26, 2004 <br />MAR 012004 <br />Division of Minerals & Geology <br />$281.00 (Due on or before your anniversary date) <br />Lincoln <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 artnu`a1 fee,-a report and-map showitrg-the-extent of curent-disturbances to-affected -__ _ <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <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 ymrr revised written annual renart and annual re~m~ to this form. please note that an <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: 103 3rd. <br />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 />~~'~ , <br />Signature of Corporate Officer, Owner, or Designee <br />D2 ~o~~ `~ <br />Date <br />M:~PERMITMASTERn000MENTSNS-AF-09 <br />