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2 <br /> <br />~ ~ ~ 7 206 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~(~ <br />r/ ANNTJAT. FF.F, and REPORT RF,QTTF.ST <br />;/ K Holsinger <br />M-1980-052 <br />Holsinger Gravel Pit <br />Apri123, 2006 <br />$281.00 (Due on or before your anniversary date) <br />Jackson <br /> <br />Divaron of Minerals end Geolo9Y <br />According to C.R.S. 34-32.5-I 16 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an operator <br />shalL~uhmit the annual fee. a.renort and_ man showing the extent of current disturbances to affected land, <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 your revised written annnal report and annual rennrt 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 report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Keith Holsinger <br />Permittee Name: K Holsinger <br />Address: P.O. Box 37 <br />Walden, CO 80480 <br />Phone Number:_ _ (970) 723-4587 <br />Fax Number: (970) 723-4771 <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 aze enclosed. <br />P <br />Si ature of orporate Officer, er, or Designee <br />~~.`>~© ~ <br />Date <br />d1 <br />