2009-11-23_REPORT - M1992060

• Permit No: M1992060
• IBM Index Class Name: REPORT
• Doc Date: 11/23/2009
• Doc Name: Annual Fee/Report/Map
• From: City of Monte Vista
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Media Type: D
• Archive: No

*- Re T-
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE
ANNUAL FEE DUE:
COUNTY:
ANNUAL FEE and REPORT REOUEST
City of Monte Vista
M-1992-060
Lagoon Pit
October 20, 2009
RECD
NOV L 3 2009
Qi n of Recla r.d.,,?
Mining and safety
$323.00 (Due on or before your anniversary date)
Rio Grande
According to _C.R.S.334-3.2.5-1_16 or C.R.S. 34-32-116, each___year,__o the anniversary date of the permit, an
operator rill 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 your 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 maw. 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 may 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: Don Van Wormer
Permittee Name: City of Monte Vista
Address: 4 Chico Camino
Monte Vista, CO 81144
Phone Number:
Fax Number;
[phone]
[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
losed.
Signature of Corporate Officer, Owner, or Designee
Date
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