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>. i'i <br />~n <br />ANNUAL FEE and REPORT REQUEST <br />RECEIVED <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Washington County <br />M-2001-012 <br />Shook Gravel Pit 1 <br />May 31, 2002 <br />1 '~ <br />MAY 0 2 200? <br />Division of Minerals and Geology <br />$688.00 (Due on or before your anniversary date) <br />Washington <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 />land, reclamation accomplished to date and during [he preceding year, new 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 your revised written annual report and annual report mao to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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: Charles J. Kuntz <br />Permittee Name: Washington County <br />Address: <br />Phone Number: <br />150 Ash St. <br />Akron, CO 80720 <br />(970)345-2701 <br />Fax Number: (970) 345-2702 <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 />Signature of orporate icer or Owner <br />Date <br />M:NERMnN4ASTERD000MEMSU4-AF-04 <br />