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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />1/1~ry~ w,wyAl 4 <br />V_' , <br />Phillips County 'rr" ""` <br />i/M-2004-052 <br />Rafert Pit <br />September 20, 2005 <br />$281.00 (Due on or before your anniversary date) <br />Phillips <br />~-~~-os <br />~ v ,C~~1(r <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 9ltnch ymm revised written anm~al report and snnnal rennrt main 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: Randy Schafer <br />Permittee Name: Phillips County <br />Address: 221 S.Interocean Ave. <br />Holyoke, CO 80734 <br />Phone Number: (970) 854-3778 <br />Fax Number: (970) 854-3811 <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 />Si~eorporate~ weer, or Designee <br />~/~/~ ~ <br />Dale <br />M:~PERMINIASTERDOCUMENTSU-f-AF-04 <br />X313 Stier°""" S~ <br />~oowt ZtJ <br />t'~ S-O LO J' <br />