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r <br /> RECEIVED <br /> NU REPP 9 JAN 13 1001 <br /> ANAL FEE and "PORT REQUEST <br /> Division of Minerals and Geology <br /> PERMITTEE NAME: David Goss <br /> PERMIT NO.: M-1985-140 <br /> OPERATION NAME: Goss Sand & Gravel <br /> ANNIVERSARY DATE: January 24,2001 <br /> ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br /> COUNTY: El Paso <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 permit, an <br /> operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br /> land, reclamation accomplislied'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 your revised written annual report and annual report map to this form. Please note that an <br /> adequately labeled ntap than clearly delineates and includes the above elements nuiv suffice Jor a written <br /> report. <br /> Division records indicate the following permittee contact information. Please verify and make any necessary <br /> changes: `A/ <br /> Permittee Contact Ak _David Goss <br /> Permittee Name: David GosstTI'` - <br /> Address: Rt. 2, 6759 Ellicott Hwv. A6 <br /> Calhan, CO 80808 , <br /> Phone Number: (719) 683-2415 -14 <br /> Fax Number: (719) 683-3290 <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 <br /> enclosed. <br /> Signa re of Corp/r4fe Officer or Owner <br /> / X22 ) 0 <br /> Date <br /> M TERMITVNASTERDOCUMENTSVNI-AF-01 <br />