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<br />FiECE~~i'E~ <br />PERMITTEE NAME; <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Costilla County <br />M-1977-044 <br />Costilla Cnty Pit 1 <br />February 25,2005 <br />$281.00 (Due on or before your anniversary date) <br />Costilla <br />FEB 2 8 2005 <br />~Jivision of Minerals and Geologp <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-newzls~r~ances 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 annual re~nrt and annual report mTn to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffece 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: Mathew Valdez <br />Permittee Name: Costilla County <br />Address: P.O. Box 130 <br />San Luis, CO 81152 <br />Phone Number: (719) 672-9109 <br />Fax Number: (719) 672-3003 <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 />~~~ v~~ <br />Signature of Corporate Officer, Owner, or Designee <br />S~zo loS <br />Dale <br />M:IPERMI'PMASTERDOCUMENTSN-I-AF-09 <br />