REP32983

• Permit No: M1986007
• IBM Index Class Name: Report
• Doc Date: 2/25/2004
• Doc Name: Annual Fee/Report Notice
• From: Glenn Southwick
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

~~ D/G
PERMTITEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Glenn Southwick
M-1986-007
Masonville Stone
March 11, 2004
FEB25~
~iyisiaa of Minerals and Geolo4V
$281.00 (Due on or before your anniversary date)
Lorimer
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 cun•ent 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 cone revised written anmral r@pnrt and annnal report m ~ to this fnrm_ Please note that an
adequately labeled map that clearly delineates and includes the above elements may suffice far a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Glenn Southwick
Permittee Name: Glenn Southwick
Address: 220 WCR 84
P.O. Box 1103
Wellington, CO 80549
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 Repor[ instructions are enclosed.
~"vl~
Signature of Corporate Officer, Owner, or Designee
~-~3-D4
Date