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T <br />h <br /> <br />ANNUAL FEE and REPORT REQUEST <br />RECEIVED <br />OCT ~ 7 :~;,2 <br />PERMI"ITEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Saguache County <br />M•1990-114 ~', <br />Noland Gulch <br />October 26, 2002 <br />$688.00 (Due on or before your anniversary date) <br />Saguache <br />Division of Minerals aad Geology <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 />operaror shall submit the annual fee, a report and map showing the extent of current disturbances to affected _ <br />land; reciama[ion accomplished-[o'date-ate- ud nng the preceding year, new disturbances that are anticipated fo <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for [he <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. 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 necessazy <br />changes: <br />Permittee Contact: John Ungefug <br />Permittee Name:-. Saguache County <br />Address: Road and Bridge <br />P.O. Box 476 <br />Saguache, CO 81149 <br />Phone Number: (719) 655-2554 <br />Fax Number: (719) 655-2543 <br />If you have additional comments and/or information that should be provided to [he 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 />ignat e of Corporate Officer, r, r ~signee <br />~6 3 a Z. ~ <br />Date <br />M:~PERM ITV.IASTERDOC UMENTSUI-AF-dl <br />