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~~~~- <br />ANNUAL FEE and REPORT REQUEST <br />PERMTI'TEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />,~ <br />jWeld Coanty ~, ,,., .- ^~ "~ <br />l M-1980-120 <br />~~~~ ~ ~' 7ftQ1 <br />Koenig Pit nstion, <br />~kjh~iaion n` a .b SaEa:Y <br />March 1, 2007 ~,nnmg <br />$$688.00 (Due on or before your anniversary date) <br /> <br />Weld <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 vour revised written annual resort and annual report map to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred durinti the arevious vear and no <br />new chanties to the previous year's map are necessary. then no new map 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: Greg Nelson d <br />Permittee Name: Weld County <br />Address: 1111 H St. <br />P.O. Box 758 <br />Greeley, CO 80632 <br />Phone Number: (970) 356-6496 <br />Fax Number: (970) 304-6497 <br />If you have additional comments and/or information that should be provided to the Division, <br />below or attach ij to this form along with your written report and map. Annual Report <br />enclosed. ~ <br />please provide it <br />instructions are <br />Signature of Cc~porate Officer, Owner, or Designee <br />Date <br />M:NERMITNIASTERDOCUMENTSNI-AF-04 <br />