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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~ ~~~r <br />ANNiJAi, FF.F, and RF.PnRT RF.[7ITF.ST <br />~P owers County <br />V M-2002-062 <br />Davis Pit <br />October 16, 2005 <br />~l <br />~~ <br />RECEIVED <br />~OCT 2 42'005 <br />~lirision of Minerals and ~ewogV <br />$688.00 (Due on or before your anniversary date) <br />Prowers <br />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 <br />-`- - operator shall-submit the annual-fee; a-report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances 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 the year, if any. <br />Please attach bmrr revised written anmral rennrt and annnal re~nrf morn to this form- Please note that an <br />adequately labeded map that cdearly delineates and includes the above elements may since 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: Mark Dorenkamp <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Prowers County <br />109 E. Sherman <br />Lamar, CO 81052 <br />(719) 336-5536 <br />(719)336-9633 <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 />"1 ~~ s~r~1y ~ <br />ignature of Corporate Officer, t7wner, or Designee <br />jD --~ / -,4.5- <br />Date <br />./ <br />M:~PERMITNIASTERDOCUMENTS4M-AF-04 <br />