2009-04-13_REPORT - M1984039

• Permit No: M1984039
• IBM Index Class Name: REPORT
• Doc Date: 4/13/2009
• Doc Name: Annual Fee/Report/Map
• From: Wilbur F Benham
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Media Type: D
• Archive: No

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ANNUAL FEE and REPORT REQUEST
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNNERSARY DATE
ANNUAL FEE DUE:
COUNTY:
Wilbur F Benham
M-1984-039
Toltec No 2
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APR ~ 200
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Apri125, 2009
$259.00 (Due on or before your anniversary date)
San Juan
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 aftectea -
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 your revised written annual report and annual resort map to this form. The Annual
Report & Fee requirement is not met until we have received the following components: fee, report, and
associated map If no new disturbances or reclamation have occurred during the previous year and no
new changes to the previous year's map are necessary, then no new map is required, provided that the
Operator shall state this in the Annual-Report. 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: Wilbur F. Benham
,~
Permittee Name: Wilbur F Benham
Address: 213 Horace Greeley Ave., #308
Norton, KS 67654
Phone Number:
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. A`n/nual Report instructions are
enclosed. ~, ~' Y' S ~' h , ~ ~ /~~ % / , /7 J j ~ ~ /1~ j'`~~ ~ ~~ /^ ~y' •~i;~.S
Signature of Corporate Officer, Owner, or esignee
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