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~1~~ <br />,.Uh ~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />V ANNiTAi. FF,F, and REPORT RF.OiTFST <br />i/ Rio Grande County <br />/ M-1987-019 <br />South Fork PiC <br />March 25, 2006 <br />RECEIVED <br />BAR i G ?C;"B <br />/Division of Minerals and 6eololY <br />$281.00 (Due on or before your anniversary date) <br />Rio Grande <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 />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 y~nnr revised written anm~al report and anneal re~nrt m n to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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: Lawrence "Buddy" Shaver <br />Permittee Name: Rio Grande County <br />Address: 168 N. Washington <br />Monte Vista, CO 81144 <br />Phone Number: (719) 852-4781 <br />Fax Number: (719) 852-0305 <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 />~~ ;~_~~ <br />Signature of Corporate Officer, Owner, or Designee <br />Date <br />M:IPERMI7'1MASTERDOCUMENTSNI-AF-04 <br />