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:. <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />rco RECEIVE® <br />'JAN 2 31006 <br />`Division of Minerals and Geology <br />ANNtiAi, FF.F. and RF.Pt1RT RF.QiiF.ST /t Iny.~,~,'-/(~',, J <br />/ Saguache County <br />M-1977-568 <br />Cooper Pit <br />November 25, 2005 <br />~ lUol.k.ir'12v! <br />$688.00 (Due on or before your anniversary date) <br />Saguache <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 XDnr revised written annnal red nrt and annnal report m ~n 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: 3otm'`P'iJilgePug <br />Permittee Name: Saguache County <br />Address: P.O. Box 655 <br />Saguache, CO 81149 <br />Phone Number: (719) 655-2554 <br />Fax Number: (719) 655-2543 <br />~/iar~a.~ ~rr~rr~o `~ <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, Owner, or Designee <br />Date <br />M:~PERMI'I~MASTERDOCUMENTSUr-AP-04 <br />