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�- -. • III IIIIIIIIIIIII III • <br /> ANNUAL FEE and REPORT REQUEST <br /> PERMITTEE NAME: Costilla County RECEWED <br /> PERMIT NO.: M-1994-103 JUN 0 4 2001 <br /> OPERATION NAME: Sierra Grande Site DIPISiOR of Minerals and Geology <br /> ANNIVERSARY DATE: June 6,2001 <br /> ANNUAL FEE DUE: $225.00(Due on or before your anniversary date) <br /> COUNTY: Costilla <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 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 map to this form. Please note that an <br /> adequately labeled map that clearly delineates and includes the above elements may 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: Elizabeth Pacheco <br /> Permittee Name: Costilla County <br /> Address: P.O. Box 100 <br /> San Luis, CO 81 152 <br /> Phone Number: (719) 672-3372 <br /> Fax Number: (719) 672-3962 <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 /> T <br /> Signature.R Corporate 6fficer or Owner <br /> ` ' �- <br /> Date i <br /> M TEKKUTVMASTERDOCUMENTSW-AF-Oi <br />