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<br /> <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~II II~II~II~~I~~ II~ <br />sss <br />ANNUAL FEE and REPORT REQUEST <br />Town of Swink <br />M-1994-004 <br />Sewer Lagoon Exp Pjt <br />February 11,2002 <br />RECEIVED <br />JAN 2 3 2002 <br />Division of Minerals and Geology <br />$438.00 (Due on or before your anniversary date) <br />Otero <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-I 16, each year, on the anniversary date of the permit, an <br />operator shall submit the annual fee, a report and map showing [he extent of current disturbances to affected <br />land, reclamation accomplished to date and during [he preceding year, new disturbarices that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for [he year, if any. <br />Please attach vour revised written annual report and annual report map to this form. Please note rlmt an <br />ndegt«tteh~ lnbelcd map that clear!}~ delineates and includes the above elements ntnv .ruffce jar n written <br />report <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />chances: <br />Pennittee Contact: Rick Dell <br />Perntittee Name: Town of Swink <br />Address: P.O. Box 267 <br />301 Columbia <br />Swink. CO S 1077 <br />Phone Number: (719) 384-71.55 <br />Fax Number: (719) 384-7951 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />\~ <br />Signature of rporate Office or Owner <br />~- ~~ ~~-, <br />Dme <br /> <br />At.~PERT7riV.1A5TERDDCUMENTSUi-AF lu <br />