2007-04-20_REPORT - M2004025

• Permit No: M2004025
• IBM Index Class Name: Report
• Doc Date: 4/20/2007
• Doc Name: Annual Fee/Report/Map
• From: Farnsworth Construction & Gravel Co.
• To: DRMS
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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AN AL FEE and REPORT REQUEST
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
/Farnsworth Construction & Gravel Co.
(/M-2004-025
North Fork Pit
April 22, 2007
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$$281.00 (Due on or before your anniversary date}
Delta
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,
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.
Please attach your revised written annual report and annual report map to this form. The Annual Report
& Fee requirement is not met until we have received the following components: fee, report, and associated
man. If no new disturbances or reclamation have occurred during the previous vear and no new chances to
the previous year's map are necessary. then no new map is required, provided that the Operator shall state
this in the Annual Report. 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: Patricia M. Famsworth
Permittee Name: Farnsworth Construction & Gravel Co.
Address: 175 Hwy 133
Paonia, CO 81428
Phone Number: [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.
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Signature of Corpora facer, Owner, or Designee
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