REP00039 ‎(2)‎

01
ANNUAL FEE and REPORT REQUEST
PERMITTEE NAME: Valco-Lamar Div REM V
PERMIT NO.: M-1977-223 FEB 03 ZM
OPERATION NAME: Wiley Pit
ANNIVERSARY DATE: February 7,2004 Uisision of Minerals&Geology
ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date)
COUNTY: Prowers
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
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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 Your revised written anm.al report and annual report map 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: Wayne Adams
Permittee Name: Valco-Lamar Div
Address: P. O. Box 591
Lamar,CO 81052
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.
A�/ Az
Signature of Corporate Officer, Owner, or Designee
/-20-10,41,
Date
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