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<br />PERMITCEE NA.~1E: <br />PERbIIT NO.: <br />OPEtt-~TION N:~~tE: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />A~iNUAL FEE and REPORT REQUEST <br />Phillips County <br />bt-1986-Od7 <br />Austin Pit <br />iVlay 5, 20~ <br />RECEIVED <br />OCT - .1'.2003 <br />Division of Minerals and Geology <br />5281.00 (Due on or before your anniversary date) <br />Phillips <br />Accordin8 to C.R.S. 34-32.8-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an <br />operator shall submit the annual fee, a repott and map showing the exten[ 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 yeaz, 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 your revised written annual report and annual report map to this form. Please note that an <br />adequately labeled map that clearly delineates and inc[tules the above elements may since 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: Randy Schafer <br />Permittee Name: Phillips County <br />Address: 221 S.Interocean <br />Holyoke, CO 80734 <br />Phone Number: (970) 8543778 <br />Fax Number: (970) 8543811 <br />If you have additional comments and/or infortna[ion 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 aze <br />enclosed. <br />Signattt~f Corpo to Of£cer or Owner <br />Dale <br />M:~PERhI n1.MA$TERD000MENfS. I-.1F-W <br />