2005-10-11_REPORT - M1990116

• Permit No: M1990116
• IBM Index Class Name: Report
• Doc Date: 10/11/2005
• Doc Name: Annual Fee/Report/Map
• From: Phillips County
• To: DMG
• Media Type: D
• Archive: No

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RECEI~~~`~
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNPJERSARY DATE:
ANNLiAL FEE DUE:
COUA~TY:
vP Ilips County
1990-116
Kennedy Pit
October 26, 2005
~~CT 1 12005
~ Division of Mint,..,. „~. ....
$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 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.
plPaCe attach vrnnr revised written annual re~nrt and anneal report map 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 following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact:
Permittee Name
Address:
Randy Schafer
Phillips County
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.
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Signature f Corporat Officer, Owner, or Designee
/o% ~G 5`
Date

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