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L .~~ <br />AN AL FEE and REPORT REQUEST <br />~~` ~ ~ ~~~ R~C~IVED <br />~AUG 0 2 2001 <br />PERMITTEE NAME: / Kiowa County ion of Reclamation, <br />PERMIT NO.: ~ M-1983-116 Mining and Safety <br />OPERATION NAME: Gentz Gravel Pit <br />ANNIVERSARY DATE: August 25, 2007 <br />ANNUAL FEE DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY: Prowers <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 />- -operatorshall submiYthe 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 far the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour 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 maa. If no new disturbances or reclamation have occurred during the previous year and no <br />new chanties to the previous year's map 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: <br />Rodney Hopkins <br />Kiowa County <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />P.O. Box 100 <br />Eads, CO 81036 <br />(719)438-5810 <br />(719)438-5327 <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 />~~ /A <br />Signature of Cq ora a Of cer, Owner, or Designee <br />Date <br />M:~PERMITMASTERDOCUMEN75U1-AF-04 <br />