2010-05-14_REPORT - M2003024

• Permit No: M2003024
• IBM Index Class Name: REPORT
• Doc Date: 5/14/2010
• Doc Name: Annual Fee/Report/Map
• From: Phillips County
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Media Type: D
• Archive: No

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE
ANNUAL FEE DUE:
COUNTY:
f ?
ANN A FEE and &OR"T REQUEST
/Phillips County
VM-2003-024
Ward Pit
May 15, 2010
$$791.00 (Due on or before your anniversary date)
Phillips
NAY 14 2010
Di,,,"n cf rte; Tams on,
741r AAinir?g and SafctY
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 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 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 suffice for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact:
Permittee Name
Address:
Randy Schafer
Phillips County
221 S. Interocean Ave.
Holyoke, CO 80734
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.
Signature orporate O icer, Owner, or Designee
Date
M: PERMIT1MASTERDOCUMENTSW-AF-04