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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Phillips County <br />M-1994.007 <br />Johnson Pit <br />May 23, 2002 <br />. f Q.J <br />RECEIVED <br />MAY 1 7 1002 <br />Division of Minerals and Geology <br />$688.00 (Due on or before your anniversary date) <br />Phillips <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 />___- operatorshall submit_the_annual_fee,_a_report and_map showing. the. extent Qf_current_di_sturbances_to_a_ffected__ <br />land, reclamation accomplished [o date and during the preceding year, new disturbances [hat are anticipated [o <br />occur during [he upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the yeaz, if any. <br />Please attach vour revised written annual resort and annual resort map to this form. Please rwte that art <br />adequately labeled map that clearly delineates and includes the above elements may since 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: Randy Schafer <br />Permittee Name: Phillips County <br />Address: 221 S.Interocean <br />Holyoke, CO 80734 <br />Phone Number: (970) 854-3778 <br />Fax Number: (970) 854-381 ] <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 />Signatu of Corporate Officer or Owner ` <br />---~-. <br />Date <br />M:~PERMITIMASTERDOCUMENTSVv1-AF-04 <br />