2007-02-21_REPORT - M1983011

• Permit No: M1983011
• IBM Index Class Name: REPORT
• Doc Date: 2/21/2007
• Doc Name: Annual Fee/Report/Map
• From: Jelen & Son, Inc.
• To: DRMS
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

PERMLTTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE
ANNUAL FEE DUE:
COUNTY:
~~y~~~
ANNUAL FEE sad REPORT REQUEST
`~Jelen & Sou, Inc.
~/ M-1983-011
Willow Creek Miae
February 23,2007
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SS225.00 (Doe oa or be[ore your antriversary date)
Lake
According to C.R.S. 34-32.5-116 or C.R.S. 34-32-I 16, each year, on the anniversary date of the permit, an
operator shall submit the annual fce, a report and map showing the extent of curent disturbances to affected
land, reclamation accomplished to date and during the preceding year, new disturbances that ere entiaipated 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 your revised w.r[tlsA *nnad relDOrt awd annual re ort moo to this form. The Annual
Report 6r Fee requirement is mot met urtll we have received the following components: tee. tetwrt. and
associated moo. If no new disturbances or reclamation have occurred durin the orevbna veer and no
new chances to tba urevtous vent's moo are necessary. rhea uo new mau is reonh•ed. mrovided that the
Operator shall state this is the Annual Report. please note drat an adequately labeled map that clearly
delineates and ineludes'the above elements may suffice jot a written report.
Division records indicate the following permittee contact information. Phase verify and make any necessary
changes: -
Permittee Contacts Kay Btecha
~.
Permittee Name: Jelen & Son, Inc. _
Address: Box 103
Gentle Rock, CO 80104
Phone Number: [phone]
Fax Number: (303) 2868688
If you have additiaral comments andlor infomation 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
rnclosed. -
' _
Signature of Corporate Office, Owner, or Designee
a._' ~ sN_ ~.7
Date
M: W ERMITM A $lpApOCrJMP117SM-AP-02.000
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