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ANNUAL FEE and REPORT REQUEST PERMITTEE NAME: PERMIT NO.: OPERATION NAME: ANNIVERSARY DATE: ANNUAL FEE DUE: COUNTY: Clyde and Marie Couch M-1989-023 Caliche School Pit March 9, 2006 e -S¢~ f~ lam ~~~'. ~~~,6751 $281.00 (Due on or before your anniversary date) Logan According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each yeaz, on the anniversary date of the permit, an operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, reclamation accomplished to date and during the preceding yeaz, new disturbances that are anticipated to occur doting the upcoming year, reclamation that will be performed during the coming yeaz, the dates for the beginning of active operations, and the date active operations ceased for the year, if any. Please attach vour revised written annual report and annual report mau to this form. The Annual Report & Fee requirement is not met until we have received the following components: fee. report, and associated maD. If no new disturbances or reclamation have occurred during the previous year and no new chances to the previous year's map are necessary. then no new maa is required. provided that the Oaerator shall state this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. Division records indicate the following pemtittee contact information. Please verify and make any necessary changes: Permittee Contact: Clyde Couch Permittee Name: Clyde and Marie Couch Address: 19956 CR 34 Rt. 2 Sterling, CO 80751 Phone Number: (970) 522-1239 Fax Number: If you have additional comments and/or information that should be provided to the Division, please provide it below or attach it to this form along with your written report and map. Annua] Report instructions are enclosed. Signature of Corporate Officer, Owner, or Designee Date