REP23343

• Permit No: M1985140
• IBM Index Class Name: Report
• Doc Date: 12/30/2003
• Doc Name: 2003 Annual Report and Fee
• From: David Goss
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE
ANNUAL FEE DUE:
COUNTY:
David Goss
M-1985-140
Goss Sand & Gravel
January 24, 2004
$281.00 (Due on or before your anniversary date)
EI Paso

('i~C:~Y V/'Efl~
DEC 3 0 2003
Division of Minerals and Geology
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 operator
shall submit the annual fee, a report and map showing the extent of current disturbances to affected land,
i8ciamation-accomplished to-date-and~during the-preeeding year,new~disturbances-that are anticipated-to-arcnr- -
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 ymrr revised written anneal report and anneal report m~ to this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may suffice for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: David Goss
Permittee Name: David Goss
Address: Rt. 2, 6759 Ellicott Hwy.
Phone Number:
Fax Number:
Calhan, CO 80808
[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.
G
Signat>~re o/f C~te Officer, Owner, or Designee
I~ 11 ~ ,~7~ 4J ?
Date
M:\PERM ITVNASTERDOCUMENTS\M-AF-01