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_, <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br /> <br />ANNUAL FEE and REPORT REOUEST'ECEIV~D <br />Lincoln County <br />M-1985-109 <br />Arthur L Schmeiser <br />August 6, 2007 <br />al.t ~ 0 3 200 <br />..1. ..I.II`.i~.... ~.. a1.JVWW~ <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 year, on the anniversary datte of the permit, an <br />operator shall submit the annual fee, a report and map showing [he extent of current disturbances [o 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 nn <br />adequately labeled map that clearly delineates and includes the above e[ernertts may s4r~ce jor a wrBtert <br />report. <br />Division records indicate the following petmittee contact information. Please verify and [Hake any necessary <br />changes: <br />Permittee Contact: Don Blake <br />Permittee Name: Lincoln County <br />Address: P.O. Box 39 <br />Hugo, CO 80821 <br />Phone Number: (719) 743-2337 <br />Fax Number: (719) 743-2838 <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 Repbrt instructions are <br />enclosed. <br />Signature of Corporate Officer or Owner <br />~7~p 9 ~0 ~ <br />Date <br />M' W ER M fMt ASTER DOC UM ENTSNI-AF-Oi <br />