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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />City of Golden <br />M-1977-534 <br />Empire Pit <br />January 30, 2005 <br />$688.00 (Due on or before your anniversary date) <br />Clear Creek <br />~~~ <br />JF~I'~ 2 ~i C~u0 <br />,..::,, ,.1. c, .~ .~y.,,, <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 ynnr revised written annul rennrt and anneal re~nrt man to this form. Please note that an <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 permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Dan Hartman <br />Permittee Name: City of Golden <br />Address: Director of Public Works <br />911 Tenth St. <br />Golden, CO 80401 <br />Phone Number: (303) 384-8000 <br />Fax Number: (303) 384-8161 <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 />~/Q.r.~ <br />Signature of Corporate Officer, Owner, or Designee <br />1 ~ 2~ ~~5' <br />Date <br />M:~PERMITMASTERDOCUMENTSNI-AF-04 <br />