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~~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Holyoke Gun Club <br />M-1977-075 <br />Holyoke Gun Club Pit <br />September 27, 2004 <br />i~~ <br />FiEDE~i/ED <br />SEP 2 ? 2004 <br />N~ <br />Division o§ Miaaral:+ ~ Geology <br />$281.00 (Due on or before your anniversary date) <br />Phillips - - - - - - - - <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 operator I <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation-aecenrpkshed-ta-date-and-during-the pre~eding-year; new-disturbances-that°are-anticipated°to occur- I <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach ym~r revised written annnal renn and annual r ~nrt man to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Gary Hershfeldt <br />Permittee Name: Holyoke Gun Club <br />Address: 20358 CR 45 <br /> Holyoke, CO 80734-9507 <br />Phone Number: (970} 854-3641 <br />Fax Number: <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 enclosed. <br />//lA1G._ /I U7YLn~ <br />Signature of Corporate Officer, Owner, or Designee <br />-!'1-D <br />Date <br />