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~F ' R~' <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />. Malouff Construction Inc. <br />~-1982-033 <br />Malouff Pit <br />October 8, 2007 <br />RE~E~~E~ <br />wl °~ ~ f Zoos <br />°tRegome <br />`~ ~n/ng end g~~~ <br />$$791.00 (Due on or before your anniversary date) <br />Conejos <br />According.to.C.R c 2A_77 5.116 or C.R.S.3_4_32=1.16, each y_ear• on the anniversary date of the permit, an operator <br />shall submit the annual fee, a report and map 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 vour revised written annual report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous year's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: Stephen Malouff .~'~ ~o ~d-`t' - ~ 7 <br />Permittee Name: Malouff Construction Inc. <br />Address: 6496 Malouff Rd. <br />Alamosa, CO 81101 <br />Phone Number: (719) 589-4198 <br />Fax Number: (719) 589-2112 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or atta h i to this form along with your written report and map. Annual Report instructions are enclosed. <br />re Corpor e facer, O er, or Designee <br />~/o - 7 - D~ <br />Date <br />