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ld o <br />~~~PPr <br />PERMITTEE NAME: ail C. Allen and Millie J. Allen ~ <br />G ECEIVED <br />R <br />PERMIT NO.: / <br />r'I41-2000-050 E <br />/O~T p 3 Z0~ <br />OPERATION NAME: Broken Spear Pit <br />ANNNERSARY DATE October 2 <br />2005 ~ Oiviaion of Minerals and Geology <br />: , <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Lincoln <br />According to C.R.S. 34_32_5-I 16 or C.R.S_34-32-11.6, each year, on the anniversary date of the permit, an operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that aze anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Pieace attach your revised written annual rern and annual rgpnr' t mar to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may su~cefor a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Gail C. Allen <br />Permittee Name: Gail C. Allen and Millie J. Allen <br />Address: 15274 Rd. N <br />der 30;,~ <br />O~ 1 1 C~ ~ ~,.~ ~ O°~ <br />Model, CO 81059 ~u ~ O 80 g Z <br />Phone Number; (719) 384-2304 ~/ ~j - 7yO - D ! S (o <br />Fax Number: 7/ 9 - ? Y 3 'a ~ ~ 9 <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 enclosed. <br />Signature of Corporate Officer, O er, or Designee <br />~'o ~ i - v S <br />Date \ ~ <br />-~ t..) a bcr..~ 1'v S .`~r~,• S t v-r. ~ ~•~..~ v1-~2 ~ `lo ~R~ ~r e~ ~'C, v ~ <br />t_. <br />