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1 • <br /> • III IIIIIIIIIIIII III • <br /> 999 <br /> ANNUAL FEE and REPORT REOUEST <br /> RECEIVED <br /> PERMITTEE NAME: Park County MAY 0 12001 <br /> PERMIT NO.: M-1995-027 Uivns'oo of Minerals and Geology <br /> OPERATION NAME: Ansley Flat Pit <br /> ANNIVERSARY DATE: April 1, 2001 <br /> ANNUAL FEE: $225.00 (Due on or before anniversary date) <br /> COUNTY: Park <br /> According to C.R.S. 34-32.5 or C.R.S. 34-32-116, each year. On the anniversary date of <br /> the permit, an operator shall submit the annual fee, a report and map showing the extent <br /> of current disturbances to affected land, reclamation accomplished to date and during the <br /> preceding year, new disturbances that are anticipated to occur during the upcoming year, <br /> the dates for the beginning of active operations, and the date active operations ceased for <br /> the year, if any. <br /> Please attach your revised written annual report and annual report map to this <br /> form. Please note that an adequately labeled map that clearly delineates and includes <br /> the above elements may suffice for a written report. <br /> Division records indicate the following permittee contact information. Please verify and <br /> make any necessary changes: <br /> PertnitteeContact: �[)uG KEITWr <br /> Pemvttee Name: -t swI 0-19UalTLI <br /> Address: 0 • IsOk 14 1 <br /> F441V-H04 I, ( .L ,. 8044D <br /> Phone Number: 7/9 n&-4 270 <br /> Fax Number: 21W E& ' 75 <br /> If you have additional comments and/or information that should be provided to the <br /> Division,please provide it below or attach it to this form along with your written report <br /> and map. ] tructions areJOpfiWjg*&%County <br /> �/ - Iha/Mt/r�OyorY*wtt <br /> Signs of Corporate Officer or Owner <br /> y�d o i <br /> Date <br />