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• iii iiiiiiiiuiu iii • <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Jerry Johnston <br />M-1982-044 <br />Glen Johnston Site 1 <br />April 23, 2001 <br />~~ <br />RE~E~V~D <br />APR ~ 4 TOOI <br />Division o/Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Teller <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 />revised written annual report and annual resort map to this form. Please note [ha[ an <br />map shat clearly delineates and includes the above elen:en[s mrry suffice for a written <br />reporl. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Jerry Johnston <br />Permittee Name: Jerry Johnston <br />Address: 13800 Hwy. 24 <br />J, <br />~ <br />~ <br />~ <br />~ <br />4 Q <br />~ <br /> r <br />/, <br />~ <br />e2 <br />m <br />X <br />Divide, CO 80814 <br />Phone Number: (7 ] 9) 687-9043 <br />Fax Number: <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 />Officer or Owner <br />Date <br />1 -mil 1 1 r <br />M.~PERM ITMASTERDOCU MENTS~hf-AF-01 <br />