2004-06-19_REPORT - M2000040

• Permit No: M2000040
• IBM Index Class Name: Report
• Doc Date: 6/19/2004
• Doc Name: Annual Fee/Report/Map
• From: Medicine Bow - Routt National Forest USDA Forest Service
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

~~
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Medicine Bow -Routt National Forest USDA Forest Service
M-2000-040
State Line Ranch Pit
June 23, 2004
$281.00 (Due on or before your anniversary date)
Jackson
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, reciama tom n accomplished-to dare and-during the preceding'yeat; new~i isturbances'that-are-amicipatcd-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 Tmir revised written anneal rennrt and anneal r~nrt man M thin form- please note that an
adequately labeled map that clearly delineates and includes the above elements may since for a written
report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Stephen Coupal
Permittee Name: Medicine Bow
Address: 2468 Jackson St.
Wyoming, CO 82070-6535
Phone Number: [phone]
Fax Number: [phone]
Routt National Forest USDA Forest Service
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 Corporate Officer, Own , or Designee
Date
~~EI4l~D
JUN 1 9 2004

ANNIiAi, FF.F, and REPORT RF, i1~ST prvisfun of Minerals K C:cr_!,gy
M:~PERMIT~MASTERD000MENTS~M-AF-04