2005-08-11_REPORT - M1984134

• Permit No: M1984134
• IBM Index Class Name: Report
• Doc Date: 8/11/2005
• Doc Name: Annual Fee/Report/Map
• From: Prowers County
• To: DMG
• Media Type: D
• Archive: No

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PERMTiTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE
ANNUAL FEE DUE:
COUNTY:
~NNi1Ai. FF,F, and RF~P,~t,7,,R_T RF.niTFST
Prowers County 0~" n'1
ti M-1984-134
Randy Shaw Pit
August 31, 2005
$688.00 (Due on or before your anniversary date)
Prowers
ldo

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AUG 1 1 2005
Divisioi
~i ~~~
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 annnai-fee,-a'relsart-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 year, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach ym~r revised written anneal report and anm~al report map to this form- Please note that 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: Mark Dorenkamp
Permittee Name:
Address:
Phone Number:
Fax Number:
Prowers County
109 E. Sherman St.
Lamar, CO 81052
[phone]
[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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i~of Corporate Offices, Owner, or Designee
7 ;Z.7 ~ o_S
Date
M:V'ERMITMAS7ERD000MENTSU.f-AF-04