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RECEIVED <br />DEC 192005 <br />PERMTTTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNiiAi. FF,F, and RF,PORT RF(liiF.ST Givision of Minerals and Geology <br />Costilla County <br />M-1980-233 <br />Costilla <br />December 11, 2005 <br />$281.00 (Due on or before your anniversary date) <br />Costilla <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 for the year, if any. <br />Please attach ym~r revised written annnal rennrt and annnal red nrt main 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 necessary <br />changes: <br />Permittee Contact: Mathew Valdez <br />Permittee Name: Costilla County <br />Address: P.O. Box 130 <br />San Luis, CO 81152 <br />Phone Number: (719) 672-9109 <br />Fax Number: <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 />Gam/ ~~~~ <br />Signature of Corporate Officer, Owner, esignee <br />~a /s /os <br />Dale <br />M:~PERMI'IVv1ASTERDOCUMENTSVvI-AF-04 <br />