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i2tvAZ <br />h.~ ~~ <br />~~~~~VE~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />v ANMiAi. FF.F and RF.PnRT RF.niTF,ST <br />t' Lincoln County <br />y ` M-1978-079 <br />Daugherty Pit <br />May 24, 2006 <br />.v- MAY 0 2200& <br />/OIV4V,:.,..., ;auneraAcaad Gealayr <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 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 />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written anmral re~nrt and annual re~nrt m ~n 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 permiitee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Don Blake <br />Permittee Name: Lincoln County <br />Address: 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 />IP't~ ~C-"~.y`~~ <br />Sign//a re of~o/rporate Officer, Owner, or Designee <br />D`/~D7 / U k~ <br />Date -~ <br />M:VPERMIrIMASTERDOCUMENTSIM-AF-04 <br />