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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Fremont County <br />D¢ 43/. ¢31¢,3. ¢b/o <br />RECEIVED <br />M-1984-117 JAN 21 <br />Fremont Gravel Pit 204 <br />Olvlflon of Minerals & Oeolapy <br />January 20,2004 <br />$281.00 (Due on or before your anniversary date) <br />Fremont <br />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 <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />- --land; reclamation-aeeomplished-to-date-and during-the preceding year; new disturbances that are anticipated-to - - <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach ymrr revised written anmlal renort and annual re o~rt map to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and tnake any necessary <br />changes: <br />Permittee Contact: CF.PR.COntaCY first name CF.PR.COntaCt last name <br />u L ~Reee- f~ - - <br />Permittee Name: Fremont County <br />Address: 615 Macon Ave 499 ~ /O S <br />Canon City, CO 81212-331•- / \ /~ ,/ ' / <br />Phone Number: '~393j-~ISi~I (_7 ~q) 7 ~~' ~"z3 `7" <br />Fax Number <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />~gnature of Corpor~te Ofificer, Owner, or Designee <br />'~=~ <br />Date <br />M:\PERMITUrASTERDOC UMENTS\hi-A F-04 <br />