2005-05-31_REPORT - M1995027

• Permit No: M1995027
• IBM Index Class Name: Report
• Doc Date: 5/31/2005
• Doc Name: Annual Fee/Report Notice
• From: park county
• To: dmg
• Media Type: D
• Archive: No

_ _,,
MAY 3 i 2005
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Park County
M-1995-027
Ansley Pit No 2
May 8, 2005
f11'lISiLL Gi 4.T.tAb;; & ~}mrq
$281.00 (Due o0 or before your anniversary date)
Park
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 for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach ynnr revised written annual red nrt and anm~al re,Pnrt 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: Robe~~aase
Permittee Name:
Address:
Park County
P.O. Box 147
Fairplay, CO 80440
Phone Number: [phone]
Fax Number: [phone]
~vE t~ouTZ. - ~I~.NL~~t~J
7i983~-man
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.
Sign re o Corporate tcer, Owner, or Designee
S ~9loS
Date
M:~PERMINIASTERDOCUMEMSUS-AF-04