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l <br />PERMITTEE NAME: <br />PERMTf NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANI~ ~~ ~ ~ l <br />AL EE and REPORT REQUEST <br />Phillips County <br />~M-1986-047 <br />Austin Pit <br />May 5, 2007 <br />,~ <br />C°~'.--~ ~ et ~~ <br />~~~R > > zoos <br />Div;:o~ o~R y <br />~ivi;~iin ,~~7~iion, <br />9 cud Safety <br />$$281.00 (Due on or before your anniversary date) <br />Phillips <br />According fo C.R:S. 34=32:5-116 Qr-G.R.-34_32116,_each year, on the anniversary date of the permit, an <br />operator shall submit the annual fee, a report and map showing the extent of currentt~~stucbances to affected-- - <br />land, reclamation accomplished to date and during the preceding year, new disturbances that aze anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming yeaz, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual report map to this form. The Annual <br />Report 8c Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred durinc the previous year and no <br />new chances to the previous year's map are necessary. then no new map is required, provided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />delineates and includes the above elements may suffice for a written 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) 854-3811 <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 />Signature Corporate facer, Owner, or Designee <br />~/ l~ ~~ <br />Date <br />M:~PERMITIMASTERDOCUMENTSNI-AF-04 <br />