2010-10-13_REPORT - M1996073

• Permit No: M1996073
• IBM Index Class Name: REPORT
• Doc Date: 10/13/2010
• Doc Name: Annual Fee/Report/Map
• From: Sedgwick 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:
AN L FEE and REPORT REQUEST
Ps ick County
M-1996-073
Dolezal Gravel Pit
November 8, 2010
$$323.00 (Due on or before your anniversary date)
Sedgwick
RECEIVED
?lr
OCT 13 2010
4 01""1" Of P lanation,
According to C.R.S. 34-32.5-116 or C.R.S. 3-4 32=rl6, 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. 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 near 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 Contact: Randy Renquist
Permittee Name: Sedgwick County
Address: 223 S Cedar
Julesburg, CO 80737
Phone Number: [phone]
Fax Number: [phone]
P542
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.
0 -'gC4 (Z '.., 1-
Signature o Corporate O tcer, Owner, or Designee
ID-s--/0
Date
M: \PERMIT\MASTERDOC UMENTS\M-AF-04