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<br />.,, <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Lincoln County <br />M-1975-079 <br />Daugherty Pit <br />May 24, 2002 <br />Rp cF~VRO <br />R 1 ~,.. <br />Ate%S% , ~J.'~ <br />aq ollyinorals andCeplo9Y <br />$281.00 (Due on or before your anniversary date) <br />Lincoln <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each yeaz, on [he anniversary date of the permit, an <br />- -operator shall-submit the annual fee, a report and map showing the extent of current disturbances to_affected _ _ <br />land, reclamation accomplished [o date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, 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 attach your revised written annual report and annual report map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Don Blake <br />Permittee Name: Lincoln County <br />Address: P.O. Box 39 <br />Phone Number: <br />Fax Number: <br />Hugo, CO 80821 <br />(719)743-2815 <br />(719)743-2838 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach i[ [o [his form along with your written report and map. Annual Report instmc[ions are <br />enclosed. <br />Signature of Corporate Officer or Owner <br />c~ ~/-05- oz <br />Dale <br />M:~PERM171MASTERD000MF.NTSV.I-AF-04 <br />