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°, ,A <br />ANATTTAT, l+'F.F, and RF,PnRT RF.nTTF.ST ~~` d 2 LUVO <br />n ~ 1111Fist~,:..4 ,.. ~,.... ~ ~~~a~ty <br />PERMITTEENAME: /Washington County ,UWJ/L;(, <br />PERMPI' NO.: d M- 2004- 021 <br />OPERATION NAME: Starlin Pit <br />ANNIVERSARY DATE: July 13, 2005 . <br />ANNUAL FEE DUE: $ 688.00(Due on or before your anniversary date) <br />COUNTY: Washington <br /> <br />According to C.RS. 34-32.5-116 or C.RS. 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 aze anticipated to <br />occur during the upcoming yeaz, 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 yeaz, if any. <br />Please attach yonr revised written annnal report and annnal report~ap to Chic form. please note that att <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 pennittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Tim Davis <br />Permittee Name: Washington County <br />Address: 150 Ash <br />Alaon, CO 80720 <br />Phone Number. (970) 345-2701 <br />Fax Number: (970) 345-2702 <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 ..~~~ ~- <br />~ignature of,E? rporate Officer, Owner, or Designee <br />~~i~e 4- <br />D~tC ' <br />M:~P -AP-04 <br />