REP17164

• Permit No: M1995026
• IBM Index Class Name: Report
• Doc Date: 8/6/2003
• Doc Name: Annual Fee/Report
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Custer County
M-1995-026
Gravel Pit M-093
August 24, 2003
$688.00 (Due on or before your anniversary date)
Custer
RECEIVCp
AUG 0 6 2003
Division ~f Minerals and Geology
According Yo-CR:S-34-32.5=116 or C:R.S: 34-32=116; -each year; on the anniversary date-of_.the pecmitran_ - _
operator sfiall submit the as-nnual -fee, a report and map showing the extent of current disturbances to affecied
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.
Ptease attach ynnr revised written anneal rennrt and anm~al rennrt m ~n 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: Gary L. Havens
Permittee Name: Custer County
Address: P.O. Box 1669
Westcliffe, CO 81252
P'honeNumber: [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.
~o ~7 ~i4~~
Signature of Corp ra e Officer, Owner, or Designee
7-a1-o3
Dale