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~ ~~ ~~~ <br />ANNUAL FEE and PORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Lincoln County <br />~zooz-o17 <br />O'Dwyer <br />March 26, 2007 <br /> <br />.~~ ~ ry ~ ~~ <br />rh~R?~z~A,~ <br />~i~j~93R c„ tKn9rajt <br />~' ~df~,ty~' <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 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 far the year, if any. <br />Please attach your revised written annual report and annual report man to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, reaor4 and <br />associated map. If no new disturbances or reclamation have occurred during the previous year and no <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: Don Blake <br />Permittee Name: Lincoln County <br />Address: P.O. Box 39 <br />Phone Number: <br />Fax Number: <br />Hugo, CO 80821 <br />(719) 743-2337 <br />(719)743-2815 <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 />enclos <br />~~~~ <br />Signature of Corpp ate Officer, Owner, or Designee <br />~~~C~ ~ ~~ 2~1~~ <br />Date <br />M:WERMITVMASTERD000MENTSUI-AF-04 <br />