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<br />v ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />/Prowers Couuty <br />,~ M-1977-387 <br />Bates Pit <br />December 1, 2006 <br />vv~ <br />~ a-1- oG~ <br />RECEIVED <br />G NOV <br />,!Division of 1 n ~~(~ <br />Mining end 8 pn <br />$$688.00 (Due on or before your anniversary date) <br />Prowers <br />According.to,CB.S_34.32.5-1_16-0~GR,S._3432-1-16,-each~eaz;-on-the-anniversary date-af-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 yeaz, 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 vour revised written annual resort and annual report roap to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, resort, and <br />associated map. If no new disturbances or reclamation have occurred durinc the previous year and no <br />new chances to the arevious year's mao are necessary, then no new maa is required, provided that the <br />Operator 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 for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: <br />Permittee Name <br />Address: <br />Phone Number: <br />Tony Gazcia <br />Prowers County <br />109 E. Sherman St. <br />Lamar, CO 81052 <br />(719)537-6631 <br />Fax Number: (719) 537-6357 <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 />Sign~~Corporate Ott3cer~ or Designee <br />/~"~~ ~ y~ <br />D [~~ <br />M:NERMIN4ASTERD000MEMS~M-AF-04 <br />