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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~~~ ~ <br />Phillips County RECEIVED <br />M-2003-024 APR 1 3 2004 <br />Ward Pit / Division o1 fNiner~l; ~ <br />May 15, 2004 <br />$281.00 (Due on or before your anniversary date) <br />Phillips <br />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 _ I <br />- - - - operator_shallsubmit the,annuaLf~e, alreport and map showing the extent of current disturbances to affected <br />- land, reclamation accomplished`to date and during the preceding ye'ai=, new disturbances that'are anticipate8 to - I <br />occur during the upcoming yeaz, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attaeh~nar revised written anneal report and anm~al re~nrt main, to this form- please note that an <br />adequately dabeled map that clearly delineates and includes the above elements may since for a written <br />report. <br />Division records indicate the following pennittee 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 Ave. <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 />~>~~~~~~ <br />Signatur of Corpo to Officer, Owner, or Designee <br />~~1~ /o '~ <br />Date <br />M:~PERMITMASTERDOCUMEMSN9-AF-09 <br />