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a <br />- ~, <br />~7~ ~~ <br />1% ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMfI' NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Otero County <br />~M-2004-027 <br />Mendenhall Pit <br />August 20, 2006 <br />RECE!!/ED <br />vAUG fl 3 2006 <br />ivision of (vlinera7s and Geology <br />$688.00 (Due on or before your anniversary date) <br />Otero <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 cm rent 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 your revised written annual report and annual report maa to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements mny suffice for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Kenneth S. Pazker <br />Permittee Name: Otero County <br />Address: 13 W. 3rd St. <br />P.O. Box 511 <br />La Junta, CO 81050 <br />Phone Number: (719) 383-3035 <br />Fax Number: (719) 383-3935 <br />[f 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, Owner, or Designee <br />~/26~0~ <br />Date ~ <br />M:~PERMITVdASTERDOCIJM ENTSVN.AF-09 <br />