2006-08-07_REPORT - M1995026

• Permit No: M1995026
• IBM Index Class Name: Report
• Doc Date: 8/7/2006
• Doc Name: Annual Fee/Report/Map
• From: Custer County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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PERMITI~EE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
>/ANNiiAi. FF.F. and RF.P(1RT RF,OiTF.ST
Custer County
t~M-1995-026
Gravel Pit M-093
August 24, 200fi
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AUG 012006
~Divisivo of Minerals and Geology
$688.00 (Due on or before your anniversary date 1
_. _, Custer _
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 reap showing the extent of current disturbances to affected
land, reclamation accomplished to date and during the preceding yeaz, new disturbances that are anticipated to
occur during the upcoming year, reclamation that will be performed during the coming yeaz, the dates for the
beginning of active operations, and the date active operations ceased for the yeaz, if any.
Plrace atiaeh vmm revised written anm.al rennrt and annnal re nn rt man to this foram, 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:
Custer County
P.O. Box 1669
-' -- Westcliffe, CO 81252-- -
Phone Number: [phone]
Fax Number: [phone]
r
i e Ct~p
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.
Signatu ~rp~rate~Oy^ r, Own r, or Designee
~.-~°
Date
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