2009-11-16_REPORT - M2005065

• Permit No: M2005065
• IBM Index Class Name: REPORT
• Doc Date: 11/16/2009
• Doc Name: Annual Fee/Report/Map
• From: Jack Clark Jr.
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Media Type: D
• Archive: No

6W i; R r
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FETE DUE:
COUNTY:
ANNUAL FEE and REPORT REOUEST
Jack Clark Jr.
M-2005-065
,""'NOV 16 2009
y*DiviSion of RecWnuttioN,
Mining and Safety
N 0 V 1
Upper Animas Sand and Gravel Pit
December 8, 2009
$323.00 (Due on or before your anniversary date)
San Juan
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-,&te=and-dur-ing-the-preceding-year, new drttn-ba miticV-ated7to -incur
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 man to this form The Annual Report
& Fee requirement is not met until we have received the following components: fee, report, and associated
man. If no ne!w disturbances or reclamation have occurred during the previous year and no new changes to
the previous year's map are necessary, then no new map is required, provided that the Operator shall state
this in the Annual Report. 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 Contract: Jack Clark Jr
Permittee Name:
Address
Jack Clark Jr.
P.O. Box 767
--- - Si-l-verton-CO-84 433
Phone Number: [phone]
Fax Number:
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.
i
a e corporate Officer, her, or Designee
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Date