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<br />RECEIVEp <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Kiowa County <br />M-1991-074 <br />Barnett Pit <br />November 12, 2004 <br />OCT 15 ?004 <br />Division oT ~.;;;,~„ ;; g GeoloBY <br />$688.00 (Due on or before your anniversary date) <br />Kiowa <br />According. toL_R.S.~4_32.5=LI6.~~C.R.S._34.32:116,_each~ear,_qu_Yhe annivers~ 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 ynnr revised written annnal report and anm~al report maT to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice 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: <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Rodney Hopkins <br />Kiowa County <br />P.O. Box 100 <br />Eads, CO 81036 <br />(719)438-5810 <br />(719)438-5327 <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 />Si ture of Corp te`6f~ic,Owner, or Designee <br />/o,~j~~o y <br />Date <br />M:~PERMITMASTERD000MENTSUr-AF-04 <br />