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F <br />~; 4 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNPJERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~~ ~~'~T <br />Lincoln County <br />~M-1977-163-SG <br />Fisher Pit <br />November 21, 2005 <br />I do <br />~+ 0 ~ L005 <br />$688.00 (Due on or before your anniversary date) <br />Lincoln <br />According_to~.R.S~4-32.5-1.16-or_C.RS.-34-32-1-16,_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 cun'ent 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 annnat report and anm~al ra~,n~nrt morn 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: 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 />~~_ <br />Signature of Corporate Officer, Owner, or Designee <br />lO-ll- OS <br />Date <br />M~PERMITNrASTERDOCUMENTSNr-AF-04 <br />