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ANNUAL FEE and REPORT REQUEST <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 i <br />February 25,2002 <br />~~ <br />DECEIVED <br />FEB 2 5 2002 <br />Division of Minerals and Geolo9Y <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 [he 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 [o date and during the preceding year, uew 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. Plence n~re that an <br />adequately labeled map drat clearly delineates and includes the above elements muy suffice for a u~rittell <br />report. <br />Division records indicate the foltowing'permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Coritac.[: Elizaheth Pacheco "' <br />Permittee Name:. Costilla Connty <br />Address: P.O. Box 100 <br />San Luis; CO 81152 <br />Phone Nwnber: (714) 672 ?372 <br />Fax Number: (719) 672-3962 <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 />tgnatu of Corpora e Officer or Owner <br />CDate <br />M 1PERM1TNIASTERD(X:UMENTSN1-AF-fM <br />