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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br /> <br />ANNUAL FEE and REPORT REQUEST <br />Saguache County <br />M-1984-044 <br />San Isabel Pit <br />June 11, 2002 <br />RECEIVED <br />JUN 0 7200? <br />Division of Minerals anQ Gealagy <br />$688,00 (Due on or before your anniversary date) <br />Saguache <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary dale of the permit, an <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances [o affected <br />` land, reclamation accomplished to date and during the preceding year, new disturbances [hat are anticipated to <br />occur during [he upcoming year, reclamation that will be performed during the coming yeaz, 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 report and annual report maa 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: John Ungefug <br />Permittee Name: Saguache County <br />Address: Road and Bridge <br />P.O. Box 476 <br />Saguache, CO 81149 <br />Phone Number: (719) 655-2554 <br />Fax Number: (719) 655-2543 <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 aze <br />enclosed. <br />S nature of Corporate O or er <br />5~2~ ~ o~ <br />Dale <br />MiPERMITMASTERDOCUMENTSN4-AF-04 <br />