2006-08-14_REPORT - M2004052

• Permit No: M2004052
• IBM Index Class Name: Report
• Doc Date: 8/14/2006
• Doc Name: Annual Fee/Report/Map
• From: Phillips County
• To: DRMS
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

-~:~~
L~ ANNUAL FEE and REPORT REQUEST
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
vPhillips County
~M-2004-052
Rafert Pit
September 20, 2006
RECEIVED
~~AUG 14 2006
vDivision of Reclamation,
Mining antl Safety
$281.00 (Due on or before your anniversary date)
Phillips
-According to C.R.S. 34-32.5-1 l6-or C.R.5. 34-32-1-i6; 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 reuort and annual resort map to this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may since for a written
report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact:
Permittee Name:
Address:
Randy Schafer
Phillips County
221 S.Interocean Ave.
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
below or attach it to this form along with your written report and map. Annual Report instructions are
enclosed.
C~/~lrm~rL ~/C~
Signature of otp/orate-yOffi r, Own/er, or Designee
~~~g6ALL/~~ Z~~r2F?
Date (~
M:NERMITWtASTERD000MENTSU4-AF-04