2005-06-14_REPORT - M1986047

• Permit No: M1986047
• IBM Index Class Name: Report
• Doc Date: 6/14/2005
• Doc Name: Annual Fee/Report Notice
• From: phillips county
• To: dmg
• Media Type: D
• Archive: No

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PERMITI'EE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Phillips County
M-1986-047
Austin Pit
May 5, 2005
JUN 1 4 2C05
Division of hli .crmis & Geulogy
$281.00 (Due on or before your anniversary date)
Phillips
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 fo 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 y mgr revised written annnal repnrr and annnal report main to this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may suffice for a written
report.
Division records indicate the fol]owing permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Randy Schafer
Permittee Name: Phillips County
Address: 221 S.Interocean
Holyoke, CO 80734
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.
Signature of rporate Of cer, Owner, or Designee
Date

M'.~PERMITMASTERDOC[JMENTS4M-AF-0q