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- ~ iii iiiiiiiiniii iii <br />.4 <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: Saguache County RECE~VEC- <br />PERI••IIT NO.: M-1977-567 N0~ Z s ZQ~~ <br />OPERATION NAME: Airport Pit OivisionotMineralsandCeitlogy <br />ANNNERSARY DATE: November 25, 2001 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Saguache <br />According to C.R.S. 34-32.5-ll 6 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 [hat 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 map to this form. F'lense note tltnt nn <br />ndequnteh• labeled map that clearly delineates and includes the above elements may srJfice for a tcritten <br />report. <br />Division records indicate the following permittee contact information. Please verify and mike any necessary <br />changes: <br />Permittee Contact: John T. Ungefug <br />Permittee Name: Saguache County <br />Address: P.O. Box 476 <br />Saguache, CO 81149 <br />Phone Number: (7i9) 6»-2514 <br />Fax Number: (719) 655-2543 <br />T,6F ~5 <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 />Sig •tture of Corporate Offi or wn <br />~, l~gla~ <br />Date <br />M. tPER A117V.IA57ER DOC Uh1EM5Nl-A F-Ol <br />lf~l! I / FUNC ~ ~.~Jv~s-.~ <br />l1PAROVAL <br />