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'C~ <br />~Jrn~- <br />RECE94~Ep <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Park County <br />M-1980-251 <br />Ansley Flat Pit <br />April 1, 2004 <br />MAR 3 0 2004 <br />Division of Minerals & Geology <br />$281.00 (Due on or before your anniversary date) <br />Park <br />_According to C.R.S. 34-32.5-116 or C.RS._34-32-1.16, each year, on the anniversary date of the permit, an <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach ymrr revised written annnal report and annual report maw to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Doug Keith ~pbe~1 "Va.,.en_ <br />Permittee Name: <br />Address: <br />Park County <br />P. O. Box 147 <br />Fairplay, CO 80440 <br />Phone Number: (719) 836-2771 C7f 91 rs$re - V Z82. <br />Fax Number: (719) 836-4275 <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 />Signaturerp~ Officer, Owner, or Designee <br />3/ea/oy <br />Dat <br />M:NERMITNrASTERD000MENTSUR-AF-04 <br />