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r~o <br />RECEIVED <br />DEC 192005 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />i, ANNiiAI. FF.F, and RF.PnRT RF,OiTEST <br />/ Rivera's Excavation <br />/ M-2004-053 <br />~ Oi~ision of Miaerala and Geology <br />Riveras Excavation Gravel Pit <br />December 29, 2005 <br />$281.00 (Due on or before your anniversary date) <br />Costilla <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 operator <br />shall submit the annual fee, a report and m_ap showing the extent of current disturbances to affected ]and, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach ynnr revised written anneal 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 suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Eleuto 7. Rivera <br />Permittee Name: Rivera's Excavation <br />Address: POB 24 <br />Amalia, NM 87512 <br />Phone Number: (505) 586-1059 <br />Fax Number: <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 />~.t ~ Ito y i/A•Cl~u/ <br />Signa~f~---~Of tOwner, or Designee <br />/.5`- Ovr <br />Date <br />