2007-01-19_REPORT - M2004038

• Permit No: M2004038
• IBM Index Class Name: Report
• Doc Date: 1/19/2007
• Doc Name: Annual Fee/Report/Map
• From: Rio Blanco County
• To: DRMS
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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ANNUAL FEE and REPORT REQUEST
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Rio Blanco County
~-1G1-2004-038
West Johnson Draw
January 7, 2007

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,tkpN 19 2001
Divi~~ ^ ^' reclamation.
p1„^ ~r end Safety
$$281.00 (Due on or before your anniversary date)
Rio Blanco
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 sfiali submit the annuai fee, a report 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 your revised written annual report and annual report map to this form. The Annual
Report & Fee requirement is not met until we have received the following components: fee, report, and
associated map. If no new disturbances or reclamation have occurred durine the previous vear and no
new chances to the previous vear's map are necessary, then no new map is required, provided that the
Operator shall state this in the Annual Report. 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 petmittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Ron Leeper
Permittee Name: Rio Blanco County
Address: 570 2nd St.
Meeker, CO 81641
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.
~s, ~'S~.eo,~_
Signature of Corporat Officer, Owner, or Designee
t2-f$-O~
Date
M:IPEAMINIASTERD000MENTS~M-AF-04