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b ~~ ~~ <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: ~ Bent County <br />PERMIT NO.: / M-1983-177 <br />OPERATION NAME: Adams Pit <br />ANNIVERSARY DATE: November 2, 2006 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Bent <br />/~ ~ ~ <br /> <br />~~QU 0 "iLt)!~; <br />Division of Reclams .~n <br />Mining and Safef,~ <br />According to C.R.S. 34-32.5-1 t6 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an <br />- - -operator-shall-submit-the-annua}-fee; a-report-ancl-map-showing-the-extent of-current-dishu~anee--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 vour revised written annual reuort and annual reuort moo to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred during the previous year and no <br />new chances to the previous year's moo are necessary. then no new moo is required, provided that the <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 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: Gary Pritchard <br />Permittee Name: <br />Address: <br />Bent County <br />P.O. Box 350 <br />Las Animas, CO 81054 <br />Phone Number: (719) 456-2223 <br />Fax Number: (719) 456-0375 <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 />c Q ~-', <br />Signature of Corporatee O fi ,Owner, or Designee <br />J'c~ -Ito - ~oDlo <br />Date <br />M:~PBRMITMASTERD000MHMSIM-AF-04 <br />