2009-10-16_REPORT - M2004052

• Permit No: M2004052
• IBM Index Class Name: REPORT
• Doc Date: 10/16/2009
• Doc Name: Annual Fee/Report/Map
• From: Phillips County
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Media Type: D
• Archive: No

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
FEL` a Ad PORT REQUEST
M.
l`Yr Phillips County
M-2004-052
Rafert Pit
OCT 16 Z00?
Division ur R-9clZm2fion,
W.Ining and Safety
September 20, 2009
$$323.00 (Due on or before your anniversary date)
Phillips
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 may to this form. The Annual
Report & Fee requirement is not met until we have received the following components: fee, report, and
associated may. If no new disturbances or reclamation have occurred during the vrevious year and no
Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly
delineates and includes the above elements may since for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact:
Permittee Name:
Address:
Randy Schafer
Phillips County
221 S. Interocean Ave.
Holyoke, CO 80734
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.
Signa gf.Corpo ie Oiricer, Owner, or Designee
--Z,QLI?'?
Date
M:\PERMrr\MASTERDOCUMENTS\M-AF-04