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5 <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Silver Mountain Preserve, Inc. <br />M-1992-003 ~trlsio £e 13 ?~~4 <br />Willis Plt notM~oorats d9o Ce%r <br />February 7,2004 <br />$281.00 (Due ou or before your anniversary date) <br />Huerfano <br />~~~~~ ~~~ <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 />---shall-submit-the~nmlal fee,-*epr?r_r_and_maa_s}towing_th~e~ctent of current. disturbances to affected land <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated 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 ynnr revised written anm~al re~nnrt and annual report map to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Travis R. Crawford <br />Permittee Name: Silver Mountain Preserve, Inc. <br />Address: 11850 CR 520 <br />La Veta, CO 81055 <br />Phone Number: (719) 742-0210 <br />Fax Number: (719) 868-2416 <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 enclosed. <br />Signature~otf Corp~o/rate Officer, Owner„g" • Designee <br />O` - / ~ ~ ~/ <br />Date <br />M:~PERMITUTASTERDOCUMEMSVN-AF-01 <br />