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'T~ <br />WIC <br />'~~~~~ ~(•',~~i; <br />PERMTI"I'EE NAME: Mask, LLC `~~ ~ ~ ,~ <br />PERMIT NO.: M-2002-087 ~i•~iaiai n; ~';la r ;' <br />OPERATION NAME: Mask Ranch Gravel Pit <br />ANNNERSARY DATE: November 25, 2004 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Archuleta <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 operator <br />shall submit the annual fee, a report and map showing the extent of cuttent disturbances to affected land, <br />- ="'=reclamatiorraccomplishetl-to -date-and=daring=the=preceding-year; new disturbances-that-are=a~ieipated 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 ynnr revised written annual report and annnal re~nrf ma,p to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following pennittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Dennis Walker <br />Permittee Name: Mask, LLC <br />Address: P.O. Box 5356 <br />Pagosa Springs, CO 81447 <br />Phone Number: (970) 264-5742 <br />Fax Number: - _ _ - <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 enclosed. <br />1 <br />Signature of Corporate Officer, Owner, or Designee <br />Date <br />