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999 <br /> ANNUAL FEE and REPORT REQUEST <br /> PERMITTEE NAME: Elbert County pe <br /> PERMIT NO.: <br /> CE�VED <br /> OPERATION NAME: DEC 1 3 20M <br /> ANNIVERSARY DATE: �`JcPtrvrtb�- �� UQ Division of'Winerals and oeolo <br /> ANNUAL FEE DUE: $281.00(Due on or before your anniversary dale) 8Y <br /> COUNTY: Elbert <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 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 report and annual report map to this form. Please note that an <br /> adequately labeled map that clearly delineates and 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: ngtt 11 izi`Vr. <br /> Permittee Name: Elbert County <br /> Address: P�oR?i 0 `I /u�e /alt e. <br /> �i rnlG C� $OY3 <br /> Phone Number: {3�- 7/7`'- 5 yl- Y ✓ <br /> Fax Number: (393}b2•t 7/,9- ,5yl <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 Corporate Officer or Owner <br /> Date <br /> M'1PER A1ITU4ASTER DOCU I.I EN TSV.t-AF-01 <br />