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~~ y <br />gas <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Washington County <br />M-1988-032 <br />Fassler Gravel Pit <br />May 18, 2005 <br />$281.00 (Due on or before your anniversary date) <br />Washington <br />,_ <br />'~ <br />tir.,~ 0 <br />wu~,~ <br />J. lHft) <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 m_ap showing the extent of current disturbanc_es_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 attnch Ymir revised written annnal re~nrt and annual re`nrt m ~n to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above a%ments may since 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: Tim Davis <br />Permittee Name: Washington County <br />Address: 150 Ash <br />Phone Number: <br />Fax Number: <br />Akron, CO 80720 <br />(970)345-2701 <br />(970)345-2702 <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 />Signature of Corporate Officer, Owner, or Designee <br />SI'~-l ~b s <br />Date <br />M:IPERMIT4MASTERDOCUMENTSIM-AF-04 <br />