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;: - .. <br />~bI~V~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />l/ p1V1VTJAT. FF.F. and REPORT RF,OTiF.ST <br />//Washington County <br />i/ M-1983-001 <br />Cecil 11-34-49 <br />May 16, 2006 <br />$281.00 (Due on or before your anniversary date) <br />Washington <br />RECEIVED <br />ti MAY Q,1 ~ <br />t/ pirisioa of Minerals and geologT <br />Accordirig'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~ccomplished_to,date,and-during.the-preceding-year,-new-disturbances-that-areanticipated-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 ymir revised written annual report and anmial rennrt maw 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 />Pennittee Contact: Lany Champ <br />Permittee Name: Washington County <br />Address: <br />Phone Number: <br />Fax Number: <br />150 Ash <br />Akron, CO 80720 <br />~/P~ ~r 3z <br />1121 ~MI ~tl <br />S~yg"y I <br />(970) 345-2701 7 7~ " ~~?j- ~f ~, <br />(970) 345-2702 ~ 7~ - ~riS 3 ' ~ >_3 <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 />// V / La~,~ vW~~.~w~ <br />igna a of •porate Of ~cer, Owner, or Designee <br />~- a6- ~~ <br />Dale <br />MiPERMINIAS7ERDOCUMF.NTSNI-AF-04 <br />