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<br />RECEIVED <br />ocr - i 2003 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Prowers Couuty <br />M-2002-062 <br />Davis Pit <br />October 16, 2003 <br />$688.00 (Due on or before your anniversary date) <br />Prowers <br />Division ~f Minerals and Geology <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-11ti, each year, on the anniversary date of the permit, an <br />operator shall submit the annual fee,, a report and ~~ showing the extent of current disturbancea_to affected-.- -____ <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 the year, if any. <br />Please attach ynnr revised written anneal report and annual report m ~ to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Jim Sidebottom <br />Permittee Name: Prowers County <br />Address: 301 S. Main St., Ste. 215 <br />Lamar, CO 81052 <br />- - Pfione Number: - (719) 336-8025 - <br />Fax Number: <br /> <br /> <br />3 3~ ' SS'3G - <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 />signature of Corporate Officer, O er, or Designee <br />~-/G ~~ <br />Dale <br />M:~PERMI7IMASTERD000M ENTSVN-AF-04 <br />