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' CJ <br />REC~IVE® <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Saguache County <br />M-1977-567 <br />Airport Pit <br />November 25, 2004 <br />NOV 2 22004 <br />Division of Minerals and GeoloBY <br />$281.00 (Due on or before your anniversary date) <br />Saguache <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-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 xgnr revised written anmral re~nnrt and annnal report m n this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice 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: John T. Ungefug <br />Permittee Name: Saguache County <br />Address: P.O. Box 476 <br />_ Phone Number: <br />Fax Number: <br />Saguache, CO 81149 <br />(719)655-2554 _ <br />(719)655-2543 <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 aze <br />enclosed. <br />Signa re of C rporate Officer, Owner, or Designee <br />(-i7-D <br />Date <br />M:~PERMI'IUTASTERDOCUMENTS~h1-AF-04 <br />