2005-06-14_REPORT - M1994007

• Permit No: M1994007
• IBM Index Class Name: Report
• Doc Date: 6/14/2005
• Doc Name: Annual Fee/Report Notice
• From: phillips county
• To: dmg
• Media Type: D
• Archive: No

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JUN 14 2UU5
PERMITTEE NAME:
PERMIT NO,:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Phillips County
M-1994-007 ~l~'
Johnson Pit
May 23, 2005
$688.00 (Due on or before your anniversary date)
Phillips
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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
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 yeaz, 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 andannnal rennrt map to this form- Please note [hat 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: Randy Schafer
Permittee Name: Phillips County
Address: 221 S.Interocean
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.
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Signature ~Corporat fficer, Owner, or Designee
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Date
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