2011-05-18_REPORT - M2000040

• Permit No: M2000040
• IBM Index Class Name: REPORT
• Doc Date: 5/18/2011
• Doc Name: Annual Fee/Report/Map
• From: Medicine Bow
• 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:
PAL FEE and REPORT REQUEST
IJAO?
Medicine Bow - Routt National Forest USDA Forest Service
/M-2000-040 RECEIVED
State Line Ranch Pit '
June 23, 2011 v{?1? 18 ear
$323.00 (Due on or before your anniversary date) ; RiVIsion of Reclamation.
Mining & Safety
Jackson
_ According to C.R.S. 34-32.5-116 or_C.R.S. 34-32-116, each year on the anniyersary date _o the permit,ean__
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 man 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: -Stephen Ceapaf-- 1Ju i„ L.e 1?e d ti
Permittee Name: Medicine Bow - Routt National Forest USDA Forest Service
Address: 2468 Jackson St.
Laramie, WY 82070-6535
Phone Number: 745-2432 3o-7 - 7 ¢S- Z. 3 i
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.
& 'W- 7 1?'
Signature of Corporate Officer, Owner, or Designee
sue// 3 lam/
Date
M: \PERMITIMAS TERDOCUMENTS\M-AF-04