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ff"~; ~T <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: / KK Holsinger REC E IuE D <br />PERMIT NO.: ~I-1980-052 i MAR 'L 6 2001 <br />OPERATION NAME: Holsinger Gravel Pit Divisc i of Reclamation, <br />~~itining and Safety <br />ANNIVERSARY DATE: Apri123, 2007 <br />ANNUAL FEE DUE: $$281.00 (Due on or before your anniversary date) <br />COUNTY: Jackson <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 />~siialT submit'the~nnual-€ee-a-report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new tstu~" rSances Ylrat~rc-a~icipated-to-occur <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 report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred durinti the previous vear and no new chanties to <br />the previous year's man are necessary, then no new map is required. provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: Keith Holsinger <br />Permittee Name: <br />K Holsinger <br /> <br />Address: <br />Phone Number: <br />Fax Number: <br />P.O. Box 37 <br />Walden, CO 80480 <br />(970)723-4587 <br />(970)723-4771 <br />no :a <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. Annua] Report instructions are enclosed. <br />or Designee <br />Date <br />