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177~'~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNI-JAL FEE DUE: <br />COUNTY: <br />j; ANNiiA1. FF.F and RRPL7RT RF,niTFST <br />v Costilla County <br />;~ M-1980-233 <br />Costilla <br />December 11, 2005 <br />,1GC~ <br />~EC~IV~D <br />~ MAR 1 r, 2006 <br />Y Drvtaron Of Minerals ann Gedogy <br />$281.00 (Due on or before your anniversary date) <br />Costilla <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 subrnit 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, rec]amation 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 />Pleas a taeh vnnr revised written anneal reFnrt and anmral re n m to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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: Mathew Valdez <br />Permittee Name: Costilla County <br />Address: P.O. Box 130 <br />San Luis, CO 81152 <br />Phone Number: (719) 672-9109 <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 />Gy''~~~~~x l~~l~~~~--- <br />Signature of Corporate Officer, Owner, esignee <br />f~.~ f.~- O~.~e <br />Date <br />M:~PERMIT WIASTERDOCUMENTS~M-AF-04 <br />