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~~;~Pi <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Conejos County <br />'~ M-1987-097 <br />La Florida Gravel Pit <br />August 18, 2007 <br /> <br />BUG Q G 2001 <br />pw ~lion of Recia~nation, <br />/ Mining and Satety <br />$323.00 (Due on or before your anniversary date) <br />Conejos <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. 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 durine the previous year and no <br />new chances to the previous year's moo 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 />Permittee Contact: Bob Lucero <br />Permittee Name: Conejos County <br />Address: 6683 County Rd. 13 <br />P O Box 157 <br />Conejos, CO 81129 <br />Phone Number: (719) 376-5772 <br />Fax Number: (719) 376-5661 <br />If you have addifional 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 />~c.u.O <br />Signature of Corporate Officer, Owner, or Designee <br />~-_/l- ~% <br />Dare ' <br />a ``' <br />M:~PERMITIMASTERDOCUMEN'lSU1-AF-04 <br />