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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Diana K. Stout <br />M-1979-103 <br />Amick Pit <br />April 8, 2002 <br />11Q <br />RECEA~~ED <br />DiYisiOrt of Mlnetals and CeologY <br />$281.00 (Due on or before your anniversary date) <br />Rio Rlanco <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 operator <br />shall submit [he annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation. accomplished to-date and durTn'g [he~p~eceding yetu~, new disturbances that are auticipated to occui <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual resort and annual resort mao to this form. Please note that an <br />adequately labeled map that clearly delineates and Includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Diana K. Stout ,,(~:'~r.ea ~ /~/n laafl <br />Permittee Name: Diana K Stout ~~ na.~ .f"' ~a fsfi~ <br />Address: P.O. Box 1056 <br /> Meeker, CO 81641 <br /> ~~&-sS~S <br />Phone Number. (970)-8-7&53.21 ~'7n - $ 7 ~' - ScQQB <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 [o this form along with your written report and map. Annual Report instructions are enclosed. <br />~1~.~trLLt ~~«d~l ~ ~~~ ~t~i~'rLe~ /~.t~i t. <br />Signature of Corporate Officer or Owner <br />Date <br />M:NERMIT VNASTERDOCUMENTSNI-AF-01 <br />