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~Pi <br />ANNUAL FE)~ and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />34-32.5-1 <br />Rio Blanco County <br />'M-1998-054 <br />East Douglas Creek Gravel Pit <br />October 5, 2007 <br />1~/"` <br />~'i. <br />~~ 'g~ ceT~~1 O <br />oase~~~~ <br />$$791.00 (Due on or before your anniversary date) <br />Rio Blanco <br />or C.R.S. <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 report 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 durinc the previous vear and no <br />new chances 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: <br />Permittee Name: <br />Address: <br />Ron Leeper <br />Rio Blanco County <br />570 Second St. <br />Meeker, CO 81641 <br />Phone Number: (970) 878-5601 <br />Fax Number: (970) 878-3396 <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, Owner, or Designee <br />9 - ~.~ _ <br />Date <br />M:~PERMI'M4ASTEADOCUMEMSN9-AF-04 <br />