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hhp <br />~ ANNUAL FEE and REPORT REQUEST 6 Z' U~` ~~ <br /> ~ <br />PERMITTEE NAME: Kit Carson County <br />PERMIT NO.: !/ M-1988-115 <br />OPERATION NAME: Ostrowski Pit <br />ANNIVERSARY DATE: December 19, 2005 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Kit Carson <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 vour revised written annual report and annual report mau to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may sujjice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Lyn Brownfield <br />Permittee Name: Kit Carson County <br />Address: P.O. Box 160 <br />Burlington, CO 80807 <br />Phone Number: (719) 346-8139 <br />Fax Number: (719) 346-7242 <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 of Corporate Officer or Owner <br />Date <br />