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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNPJERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br /> <br />Wallace F. Burtis <br />M-2001-070 <br />Florence Pit <br />August 23, 2003 <br />RECE~ VED <br />AUG 12 2003 <br />~~VISIOn ~/Minerals and Geole~y <br />$225.00 (Due on or before your anniversary date) <br />Teller <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 pemrit, an <br />-- operator shall submit the annual-fee, a report awn map showing the extent of curreni disturbances to a fected <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 ym~r revised written annnal re~nrt and annual rennrt m ~n to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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: Wallace F. Burtis <br />Petmittee Name: Wallace F. Burtis <br />Address: 66 Dartmouth Ave. <br />Pueblo, CO 81005 <br />Phone Number: (719) 566-1669 <br />Fax Number: <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 />i <br />Signature o Corporate O ,Owner, or Designee <br />~- //-e3 <br />Dale <br />M:\PERMITIMASTERDOCUM ENTS/M-AF-D2. DOC <br />