2004-10-21_REPORT - M1995046

• Permit No: M1995046
• IBM Index Class Name: Report
• Doc Date: 10/21/2004
• Doc Name: Annual Fee/Report/Map
• From: Rio Blanco County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Rio Blanco County
M-1995-046
Johnson Draw
October 7, 2004
$688.00 (Due on or before your anniversary date)
Rio Blanco
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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
-' ~i perator shall submit the annual fee, a report and map showing t}ie=extent of current disturbance"s to~affeoied
land, reclamation accomplished to date and during the preceding year; new dis„irbances that are anticipa*.ed 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 ynnr revised written annnal report and annnal report main to Chic 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: Jerry-Steele
Permittee Name: Rio Blanco County
Address: 570 2nd St.
Phone Number:
Fax Number:
Meeker, CO 81641
[phone]
[phone]
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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, Owner, or Designee
Date

MiPERMITMASTERDOCUMENTSNI-AF-04