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<br />_ _,, <br />MAY 3 i 2005 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Park County <br />M-1995-027 <br />Ansley Pit No 2 <br />May 8, 2005 <br />f11'lISiLL Gi 4.T.tAb;; & ~}mrq <br />$281.00 (Due o0 or before your anniversary date) <br />Park <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 <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to 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 ynnr revised written annual red nrt and anm~al re,Pnrt man to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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: Robe~~aase <br />Permittee Name: <br />Address: <br />Park County <br />P.O. Box 147 <br />Fairplay, CO 80440 <br />Phone Number: (719) 836-4282 <br />Fax Number: (719) 836-4275 <br />~vE t~ouTZ. - ~I~.NL~~t~J <br />7i983~-man <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 />Sign re o Corporate tcer, Owner, or Designee <br />S ~9loS <br />Date <br />M:~PERMINIASTERDOCUMEMSUS-AF-04 <br />