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-ti 'i <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />V <br />ANNUAL FEE and REPORT REQUEST <br />Dolores County <br />M-1995-010 <br />Black Snag <br />March 24, 2002 <br />RECENED <br />FEB 2 2 2002 <br />Division of Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Dolores <br />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 <br />operator shall submit the annual fee, a report and map showing the extent of curent disturbances to affected <br />land,-rec!amation-aecomp!ished 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 vour revised written annual report and annual report map 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: Tim Huskey <br />Permittee Name: Dolores County <br />Address: P.O. Box 608 <br />Dove Creek, CO 81324 <br />Phone Number: (970) 677-2328 <br />Fax Number: (970) 677-3759 <br />If you have additional comments and/or information that should be provided [o 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 />Signature o rporate Officer or Owner <br />~ /~/®a <br />Date <br />M:IPERMITtMASTERDOCUMENTSIM-AF-6{ <br />