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~ <br />~ANNiiAi. FF.F, and RF.PnRT RF.(7iTFST - <br />r ~__~ <br />PERMITTEE NAME: Logan County Ji;'re I ~ [,,;,~ <br />PERMIT NO.: M-1987-159 ~~ n* : '.~~i~' <br />OPERATION NAME: Guenzi S & G Pit <br />ANNIVERSARY DATE: December 28, 2004 <br />ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br />COUNTY: Logan <br />According to C.R.S. 34-32.5-1 i6 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 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 year, reclamation that will be performed during the coming year, the dates far the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach ynnr revised written anneal re~nrt and annual re~nrt m ~n M 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: <br />Permittee Name: <br />Byron Hickox <br />Logan County <br />Address: <br />Phone Number: <br />Fax Number: <br />315 Main St., Ste. 2 <br />Sterling, CO 80751 <br />(970)522-0888 <br />(970)522-4018 <br />If you have additional comments and/or information 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 are <br />enclosed. <br />~_l I - <br />Signatur of Corporate Officer weer, or Designee <br />/a~a9~ot~ <br />Date ~ <br />M:~PERM171MASTERD000MENTSVvl-AE-04 <br />