REP45260

• Permit No: M1984154
• IBM Index Class Name: Report
• Doc Date: 11/24/2004
• Doc Name: Annual Report and Fee
• From: City of Lamar
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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PERMITTEE NAME: City of Lamar (~QV 1 ~ ZG~~
PERMIT NO.: M-1984-154
OPERATION NAME: Well Field Pit
ANNIVERSARY DATE: December 10, 2004
ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date)
COUNTY: Prowers
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 fe_e, a report and map showing_the extent of current disturbances to affected -
land, reclamation acc'omplished'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 anm~al report and anm.al report mttp 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: Patrick Mason
Permittee Name: City of Lamar
Address:
Phone Number:
Fax Number:
102 E. Parmenter St.
Lamar, CO 81052-3239
[phone]
[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 Corporate Officer, Owner, or Designee
Date
M:~PERMI7 VNASTERDOCUMENTSUI-AF-04