REP47814

• Permit No: M1987009
• IBM Index Class Name: Report
• Doc Date: 1/24/2005
• Doc Name: Annual Report and Fee
• From: Prowers County
• 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:
Prowers County
M-1987-009
Jones Pit East
February 26, 2005
Jnl`d 2 ~. ~ -
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pivision of ttiinersls F: Cnnlniy
f-t V V U
$688.00 (Due on or before your anniversary date)
Prowers
_ 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, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to
occur during the upcoming year, reclamation that will be performed during the coming year,-the dates"foi the '
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach ynnr revised written annual report and annnal re~nrt man to this 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: Mark Dorenkamp
Permittee Name: Prowers County
Address: 301 S. Main, Ste. 215
Lamar, CO 81052
Phone Number: [phone]
Fax Number: [phone]
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.
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tgnature of Corporate Of er, Owner, or Designee
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0
Date
M:~PERMI'MIASTEADOCUMEMS~h1-AF-04