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RECEIVED <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Phillips County <br />M-1983-050 <br />State Land-Jensen Pit <br />April 28, 2002 <br />MAR 2 0 2002 <br />Division of Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Sedgwick <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 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 [hat 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 your revised written annual report and annual resort 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 pemtittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Randy Schafer <br />Permittee Name: Phillips County <br />Address: <br />Phone Number: <br />Fax Number: <br />221 S.Interocean <br />Holyoke, CO 80734 <br />(970)854-3778 <br />(970)854-3811 <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 instmctions are <br />enclosed. <br />Signatur of Corpor Officer or Owner <br />/~d 2 <br />Dale <br />M:~PERMTnMASTERDOCUMENTSVVt-AF-04 <br />