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/ ~ 1 <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />l Jackson County <br />~M-1977-472 <br />BLM East Gravel Pit <br />January 25, 2007 <br /> <br />RF~F~~~o <br />°%~/FFB ~8 <br />L Mnn9d asamO~on <br />ty <br />$$688.00 (Due on or before your anniversary date) <br />Jackson <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 yeaz, new disturbances that are anticipated to <br />occur during the upcoming yeaz, 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 resort and annual resort 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 during the previous year and no <br />new chanties 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: Nelson Selcer <br />Permittee Name: Jackson County <br />Address: 188 Grant Street <br />_ _ _ P.O. Box 488 <br />Walden, CO 80480 <br />Phone Number: (970} 723-4481 <br />Fax Number: (970) 723-8437 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or atta~c~h~it(~to this fo~ ith your written report and map. Annual Report instructions are <br />enclosed. `l .Y-x-~~ <br />Signature of Corporate Officer, Owner, or Designee <br />2~ 2c~~O7 <br />Date <br />M:1PERhaTUMSTERDOCUMENTSUvI-AF-04 <br />