2005-08-17_REPORT - M1994077

• Permit No: M1994077
• IBM Index Class Name: Report
• Doc Date: 8/17/2005
• Doc Name: Annual Fee/Report/Map
• From: Washington County
• To: DMG
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
~~ ,,
LLW~~ashington County ~-T - ~
~/M-1994-077
Nickell Gravel Pit
August 25, 2005
R~>/~1~~"~"~
/pUG 17 2005
'~ pivision of Minerals anu ~~'~~
$281.00 (Due on or before your anniversary date)
Washington
- According to C:R:S.-3432.'5-1"16 of C~R:S-34-32=116-e3ch-'year; on the anniversary date ofthe-permit,-"an
- - -operator-shall-submit-the-annual fee,-a-report_and_map showinglhe_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 re~nrt and annual report man 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:
Permittee Name:
Address:
Phone Number:
Fax Number:
Larry Champ
Washington County
150 Ash
Akron, CO 80720
[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.
~Q~ ~a
ign a ~/ orporate Of icer, Owner, or Designee
$`$~yJ
Date
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M: WERMITMASTERDOCUMEMSyN-AF-04