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~~ Pi <br />AN AL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Costilla County <br /> <br />RECEIV~® <br />.~M-1994-103 /1JUN 13 2001 <br />Sierra Grande Site Bivision of keclamation, <br />Mining and Safety <br />June 6, 2007 <br />$$281.00 (Due on or before your anniversary date) <br />Costilla <br />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-I`ee, a report an map showing t e extent of current ~stur anc`es o~affected---- <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 vour revised written annual report and annual report 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 durin¢ the previous year and no <br />new changes 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: Mathew Valdez <br />Permittee Name: Costilla County <br />Address: P.O. Box 130 <br />San Luis, CO 81152 <br />Phone Number: (719) 672-9109 <br />Fax Number: (719) 672-3003 <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 />G~~~ Ut~l.~~ <br />Signature of Corporate Officer, Owne , or Designee <br />~ ~~ ~a ~ <br />Date <br />MiPERMINrASTERDOCUMENTSNt-AF-04 <br />