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l~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <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 map showing_ the extent of current disturbances to affected <br />fend;-reefamafian-aeearnp3isired-ta-datcand-duringthe-p r, '~ a~ are annctpa e o <br />occur during the upcoming year, reclamation that will be performed during the coming year, [he 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. Please trote that an <br />adequately labeled map that clearly delineates curd includes the above elements may suffice 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: Elizabeth Pacheco <br />Permittee Name: <br />Address: <br />ANNUAL FEE and REPORT REQUEST <br />Costilla County <br />M-1980-233 <br />Costilla <br />December 11, 2002 <br />RECEIVED <br />DEC ' 1 ^`~JZ <br />Division of Minerals and Geology <br />$251.00 (Due on or before your anniversary date) <br />Costilla <br />Costilla County <br />P.O. Box 100 <br />San Luis, CO 81152 <br />Phone Number: (719) 672-3372 <br />Fax Number: <br />e05Yt1~1-.A CoUn~TX <br />(J. O . talO X 17 b <br />5t9N h~~s Co sltsz, <br /> <br />If you have additional comments and/or information that should be provided to [he Division, please provide i[ <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, Own , or Designee <br />iz~~lDZ, <br />Date <br />M:~PERMITMASTERD000MENTSVN-AF-04 <br />