2005-09-20_REPORT - M1992060

• Permit No: M1992060
• IBM Index Class Name: Report
• Doc Date: 9/20/2005
• Doc Name: Annual Fee/Report/Map
• From: City of Monte Vista
• To: DMG
• Media Type: D
• Archive: No

rcU ~-
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
AF ~RPr
City of Monte Vistad~'/~
vNI-1992-060
Lagoon Pit
October 20, 2005
$281.00 (Due on or before your anniversary date)
Rio Grande
RECEI!/EC
vSEP 2 0 10~
YU Division of Minerals and geology
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 annul fee,-a report and map showing the extent of-current~isfur~nces to af£ecte~lt -- `-'
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 ymrr revised written annnal re~nrt and annnal rennrt m ~n 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: Don Van Wormer
Permittee Name: City of Monte Vista
Address: 4 Chico Camino
Monte Vista, CO 81144
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.
V
Signature of Corpora~t'4e~OfficeCr~, Owner, or Designee
Date
M: W ERMITU9ASTERDOCUMENTS~M-AF-04