2010-09-14_REPORT - M1977075

• Permit No: M1977075
• IBM Index Class Name: REPORT
• Doc Date: 9/14/2010
• Doc Name: Annual Fee/Report/Map
• From: Holyoke Gun Club
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Media Type: D
• Archive: No

A AL FEE and REPORT REQUEST
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
P Holyoke Gun Club
41977-075
Holyoke Gun Club Pit
September 27, 2010

CISVED
?LP 14 20 irk
Division ut nac,4matian,
-? Mining and Salty
$$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 upcorriin`g year,-"reclamation that Will-Ge performed-during the coming year,--tfi-e aces 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. The Annual Report
& Fee requirement is not met until we have received the following components: fee, report, and associated
map. If no new disturbances or reclamation have occurred during the previous year and no new changes to
the previous vear's map are necessarv. 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 Contact: Ross Brinkema
Permittee Name: Holyoke Gun Club
Address: 58700 Rd. FF
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
ar attac t to this f rm along with your written report and map. Annual Report instructions are enclosed. - X ?%t
Sign ure of Corporate Officer, Owner, or Designee
,(0 r-1 V
Date