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~~ ~- <br />ANNU~FEE and REP ~ T REQUEST <br />PERMITTEE NAME: ~ Robert Daugherty ~~'~` ~ ~\/~ <br />PERMIT NO.: iM-2004-048 ~, ACT ~ ~ ZQO7 <br />OPERATION NAME: Cedar Point Picture Rock Quarry <br />Division of Reclamation, <br />ANNIVERSARY DATE: October 4, 2007 ~ Mining and Safety <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COiJN'PY: San Miguel <br />According to C.R.S. 34-32.5-116 or C.R.S. 34_32-116. eaCh~tear,on the_anniversary.date.o~the-perm~i,au-eperater- <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />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 Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous veer and no new chances to <br />the urevious year's map are necessary. then no new mau is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />above elements may suffice jor a written report. <br />Division records indicate the following pennittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Robert Daugherty <br />Permittee Name: <br />Address: <br />Robert Daugherty <br />P.O. Box 1364 <br />Phone Number: <br />Fax Number: <br />Clifton, CO 81520 <br />(970)434-8773 <br />(970)242-8438 <br />If you have additional comments and/or information that should be provided to the Division, please provide <br />below or attach it to this form g with your written report and map. Annual Report instructions are enclosed. <br />S' ature o Co rate ~cer, Owner, or Designee <br />D%/~~ <br />