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<br />i, <br />r _ <br />~~ ~ ~~~~~ <br />ANNUAL FEE and REPORT REQUEST <br />RECEIVED <br />DEC 10 2001 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />David Goss <br />M-1985-140 <br />Goss Sand & Gravel <br />January 24, 2002 <br />$281.00 (Due on or before your anniversary date) <br />EI Paso <br />Division of Minerals and Ceelogy <br />According to C.R.S. 34-32.5-1 16 or C.R.S. 34-32-1 l6, each year, on the anniversary date of the permit, an operator <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 iFie 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 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 sauce for a written report. <br />Division records indicate the following permit[ee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: David Goss <br />Permittee Name: David Goss <br />Address: Rt. 2, 6759 Ellicott Hwy. <br />Calhan, CO 80808 <br />Phone Number: (719) 683-2415 <br />Fax Number: - -(7-19) 583-3290 - - - -- - - ~~ ~~ ~- - <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 enclosed. <br />Signal(ure of Corp~te Officer or Owner <br />i~ l~/~~ <br />Date <br /> <br />M.~PER M I"MIASTER DOCU AIEMSUI ~ AF-01 <br />