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,~ <br />P~tRPT <br />PERMITTEE NAME: <br />PERMTT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Phillips County / <br />M-1990-116 / <br />Kennedy Pit <br />October 26, 2007 <br />RECENED <br />SEP 13 2007 <br />n of Reclamation, <br />N6ning and Safety <br />$$323.00 (Due on or before your anniversary date) <br />Phillips <br />According to C.R.S. 34-32.5-116 or C.R.S. 34_32-116,-eac~y_ear on_the_annixersary_date_oLthe_perrnit,_an <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 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 during the previous veer and no <br />new chances to the previous year's man 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 uaitten report. <br />Division records indicate the following petmittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Randy Schafer <br />Permittee Name: Phillips County <br />Address: 221 S. Interocean <br />Holyoke, CO 80734 <br />Phone Number: (970) 854-3778 <br />Fax Number: (970) 854-3811 <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 />C~~~~ <br />Signature orporate O cer, Owner, or Designee <br />9/io l~ ~ <br />Date <br />M:~PERMITVNASTERDOCUMENTS~hf-Ar-04 <br />