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S <br /> <br />V <br />RECEIV~~ <br />APR 2 3 ~~_~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Park County <br />M-1995-027 <br />Ansley Pit No 2 <br />Vlay 8, 2003 <br />$281.00 (Due on or before your anniversary date) <br />Park <br />Division ~f MinEfdls and Geology <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 annual fee, a report and map showing the extent of current 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 />bed nning of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annnal red ort and annual rq~prt martn this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffZCe 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: Doug Keith <br />Permittee Name: Park County <br />Address: P.O. Box 147 <br />Fairplay, CO 80440 <br />Phone Number: (719) 836-4270 <br />Fax Number: (719) 836-4275 <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 instmctions are <br />enclosed. <br />s*~ G/~ <br />Si azure of Corporate Officer, Owner, or Designee <br />5~/s/a3 <br />Date <br />M:~PERMIPMASTERDOCUMENTS~M-AF-04 <br />