2009-04-14_REPORT - M1995027

• Permit No: M1995027
• IBM Index Class Name: REPORT
• Doc Date: 4/14/2009
• Doc Name: Annual Fee/Report/Map
• From: Park County
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Email Name: DB2
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
ANNUAL FEE and REPORT REQUEST
Park County
M-1995-027
Ansley Pit #2
May 8, 2009
$323.00 (Due on or before your anniversary date)
Park
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APR 14 200:,
Divi'On 01 Kecl?mation,
Mir,?r?g and SafetyC?
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 your revised written annual 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: David Kintz
Permittee Name: Park County
Address: P.O. Box 147
Fairplay.CO 80440
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.
Signature of Corporate Officer, O er, or Designee
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