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<br />~F ~- RPM <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REpUEST <br />Bent County <br />M-1983-177 <br />Adams Pit <br />November 2, 2007 <br />Ro ~~~VE <br />oi~isoCT 9 ~?pp~ ..~ <br />Minn9a vesa~~ on, <br />$$323.00 (Due on or before your anniversary date) <br />Bent <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-tadate and during the 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 resort and annual resort maa to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred durinti the previous year and no <br />new chanties to the previous year's moo are necessary, then no new map is required, provided that the <br />Ouerator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />delineates and includes the above elements may since jor a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: 6my~ritcliacd <br />Permittee Name: <br />Address: <br />Bent County <br />P.O. Box 350 <br />Las Animas, CO 81054 <br />Phone Number: (719) 456-2223 <br />Fax Number: (719) 456-0375 <br />.u`J <br />`. .. <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 />~ Q . <br />Signature of Corporate Officer, weer, or D ignee <br />~o - ~-3 , ~.t~y <br />Date <br />M:~PERMINIASTERD000MEMSNI-AF-04 <br />