2003-12-11_REPORT - M1989112

• Permit No: M1989112
• IBM Index Class Name: Report
• Doc Date: 12/11/2003
• Doc Name: Annual Fee/Report Notice
• From: Moffat County
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

PERMI'I'TEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
ferry Nichols
M-2000-022
Molina Gravel Company
December 12, 2003
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of M:ra^.;a', . .
$281.00 (Due on or before your anniversary date}
~,4a'6d
_ ~ of ~..., 4-32-1 L. .,~. _ ., ~ ..
." o .Pnor 'map shc:.•:.o _ - =tu:_ ~. -G~ apt ,
reclamation accompiisneci 1~ ~,,,:..,:.: _a~-:~g the preceding year, new disturbances tila
during the upcoming year, reclamation that will be performed during the coming year, thr sates for th • beg,;,ning
of active operations, and the date active operations ceased for the year, if any. -'
Ple,.. .;r that an
adequately labeled map thnt clearly delineates and includes the above elements may suffice jor ~ ri'ten reyort.
P.ivision recnrd~ indicate the follfowing permittee contact infomtation. Please verify ~~+d make any necessary
changes: -
Permittee Contact: Terry Nichols ~`~ C ~- _ ~ ~~ _
Permittee Name: Terry Nichols ____ _______~ _
Address: i'. O. Box 37 ~'"~- ~`~ _ _f~+O QQ
535 Hwy, 330 _~ ~~ ~ ~'ow1 ~Q._`~~`J~
Molina, CO 81646 ~7 U='^~ y__' _b~j~J~ __ __. _
Phone Number; [phone] _~_
Fax Number: [phone] _ _ __ -__._ __
If you have additional comments and/or infottnation thst should be provided to :he 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 of orporate Officer, Owner, or Designee
I~ - s- ~ 3
Date
M?PER M ITUTASTERDOCUM ENTS :M-AF-01
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