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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />Lincoln County <br />M-1978-078-SG <br />George Ansley Pit <br />May 24, 2007 <br />$$281.00 (Due on or before your anniversary date) <br />Lincoln <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 shall submit the annual fee, a report and map showing the extent 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 yeaz, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual report map to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred durinc the previous year and no <br />new chances to the previous year's map are necessary, then no new map is required, provided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />PermitteeContact: Don Blake Don Blake is no longer contact <br />PermitteeName: Lincoln County person due to health problems. <br />Address: P.O. Box 39 <br />Hugo, CO 80821 <br />Phone Number: (719) 743-2337 <br />Fax Number: (719) 743-2815 <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 />~ ~• l-Il/GG~.s. a ~1P2 ~ ,~ "~t~17~: `~~'~ynt~~~w <br />Signature of Co •ate Officer, caner, or Designee <br />il~ ~ mil/ `~ <br />Dat <br />M:~PERMIINIAS7ERDOCUMENTSUS-AF-04 <br />