2005-06-13_REPORT - M1994103

• Permit No: M1994103
• IBM Index Class Name: Report
• Doc Date: 6/13/2005
• Doc Name: Annual Fee/Report Notice
• From: costilla county
• To: dmg
• Media Type: D
• Archive: No

~ V
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE
ANNUAL FEE DUE:
COUNTY:
Costilla County
M-1994-103
Sierra Grande Site
June 6, 2005
$281.00 (Due on or before your anniversary date)
Costilla
JUN 1 ~, P005
Division of &{rnera!s G GeuloDy
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
operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected
land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to
occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach ym~r revised written annnal rennrf and annnal repnrf main to this form- Please note that an
adequately labeled map that clearly delineates and includes the above elements may suffice for a written
report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Mathew Valdez
Permittee Name: Costilla County
Address: P.O. Box 130
San Luis, CO 81152
Phone Number: [phone]
Fax Number: [phone]
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are
enclosed.
~~~~~ ~c~~d~
Signature of Corporate Officer, Owner, r Designee
(a /7 /os'
Date
M:~PERMINrASTERDOCUMENTSVvt-AF-04