2009-09-17_REPORT - M1994077

• Permit No: M1994077
• IBM Index Class Name: REPORT
• Doc Date: 9/17/2009
• Doc Name: Annual Fee/Report/Map
• From: Washington County
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Media Type: D
• Archive: No

,if ," W- ? 7-
ANNUAL FEE and REPORT REOUEST
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
?i(IWashington County
,4-1994-077
Nickell Gravel Pit
August 25, 2008
$791.00 (Due on or before your anniversary date)
Washington

pfflCF,M'D
/SEP 17 2009
Division of reclamation,
110 Mining and Safety
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 vour revised written annual report and annual report 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 durine 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 suffice for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Board of County Commissioners CF.PR.contact last name
Permittee Name:
Address
DUN RIEMi=NSCHNi=IDFR
Washington County
150 Ash Avenue
Akron, CO 80720
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.
Signatur o Corpora e Of icer, Ow er, or Designee
Date
M:IPERMITqviAS TERDOCUMENTS\M-AF-04