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l~1 <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: Kiowa County RECE-~/ED <br />PERMIT NO.: M-1983-119 A(1~ D ~ ~2 <br />OPERATION NAME: Chivington Grazing Division of Minerals and GeoloBY <br />ANNIVERSARY DATE: August 25, 2002 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Kiowa <br />According [o 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, 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 Vour revised written annual report and annual report map 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 permi[tee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Rodney Hopkins <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <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 instmctions are <br />enclosed. <br />Signature of C rpora[e Officer or Owner <br />~~~f ~oZ <br />Dale <br />M iPERMITNIASTERD()CUMENTSUd-AF-04 <br />