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III IIIIIIiIIIIII 'll <br /> ANNUAL FEE and REPORT REQUEST <br /> --n <br /> PERMITTEENAME: City of Lamar RE'->> ` <br /> PERMIT NO.: M-1984-154 'Ir J 1 <br /> bl: <br /> OPERATION NAME: Well Field Pit <br /> ANNIVERSARY DATE: December 10,2000 Division of lwli0a-"3 Gcolcy <br /> ANNUAL FEE DUE: S281.00(Due on or before your anniversary date) <br /> COUNTY: Prowers <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 your revised written annual report and annual report map 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: Patrick Mason <br /> Permittee Name: City of Lamar <br /> Address: 102 E. Parmenter St. <br /> Lamar, CO 81052-3239 <br /> Phone Number: (719) 336-4495 <br /> Fax Number: (719) 336-4404 <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 /> Signature of Corporate Officer or Owner <br /> t � - `(- oo <br /> Date <br /> M\PEPMITV.4ASTEP-DOCUMENTSIvI-AF-04 <br />