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<br /> I~a , <br /> ~ ~T <br /> <br />PERMITTEE NAME: ANNTIAT. FF.F. and R <br />Prowers County F.PnRT RFOTTFST <br />~D~ <br />PERMIT NO.: ~M-1984-136 <br />OPERATION NAME: Brann Pit <br />ANNNERSARY DATE: August 31, 2005 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Prowers <br />~- ~3-oS <br /> <br />~ ; ~~ <br />According-to C.R,S. 34-32^5-116 or C.R.S. 34-32-116, each yeaz, on the anniversary date of the permit, an <br />operator shad submiCthe-annuai-fee,-a-report and-map showing_the_exten{ of current disturbances to affected <br />land, reclamation accomplished 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 ynnr revised written anneal report and anneal rennrt m~ 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 pennittee contact information. Please verify and make any necessary <br />changes: <br />Permiitee Contact: Mark Dorenkamp <br />Permittee Name: <br />Address: <br />Phone Number: <br />Prowers County <br />109 E. Sherman St. <br />Lamar, CO 81052 <br />(719)336-5536 <br />Fax Number: (719) 336-9633 <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 />Signature of Corporate Officer, O~ ner, or Designee <br />`_ ~^d~ <br />Date <br />MiPERMITNrASTERDOCUMENTSUI-AF-04 <br />