2005-06-14_REPORT - M2004023

• Permit No: M2004023
• 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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PERMITTEE NAME: P/th hips County ~ JUN 14 2005
PERMIT NO.: °'M-2004-023
OPERATION NAME: Haynes Hereford Ranch Pit D~risia;.
ANNIVERSARY DATE: June 2, 2005
ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date)
COUNTY: Phillips
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 fo 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 XDnr revised written annnal report and anmial report mgp, M this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may suffice 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:
Address:
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.
Signatur of Corpor Officer, Owner, or Designee
Date
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