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Sep~15 07 03:18p Mike Koellner, Owner 9707746114 p.2 <br />PERti;i'I`fEE Nr~A4E: <br />1~ERis?}T NEB.: <br />(}PERhTiC)1*' ia'f~?YIE: <br />f1;4I~}?VEPsSAIiY }3~S I"~: <br />~iv^stiAL FEE l3UE: <br />C;JL?jrrl"Y: <br />AN~UA~. ~ asx} R~P€TR"$' RE4AE7~~ <br />~, a& d~ Fgeady ti'six <br />P++1-a99~-€T5~ <br />~attatay S3aFe ixarta Pif <br />Sepfee-nbxr 55, 2fli}? <br />SS7~3.4f1(i~ae oat or lte€'or2 your aaativersary xlate) <br />~}tP118itS <br />.F?ccor3irtg to C.Y2.S. 3-3-3.5-115 or ".R.S. 34-32-1 }G, eacts year, an She anniversary date a#~ t}te permit, an operator <br />s»aii sui;rsait -:c; anneal fee, a report anti ma{; shact•ing the c:terat of cxcrrert disttarbanccs ao a#'fected land, <br />rcxla,-naiian accorr:glishGd to date arx} ~csring thG preeedht~ year, new d#stu.~arcGS fleet are anticipated to occur <br />curistg the upGantinK year, reGlamatioaa :hat will hG perfoasraed xia€ring flee corstiraS year, flee dates iar the l~ainning <br />o`active aperations, ease the elate aceive aperatians eeascxl for the year, ifany. <br />P}ease atcax;l, yoar revisexl svrat@e;t aataaa[ rsmmst :taxi aacaatal reYSaarf satagt Qo fifes fxsxaa. Tice e~ttttttal 12elaort <br />~: Fee °egaairnanettt is not ttaet aaatai aver i€ave rece4v:a ire €'o{txawaag eneaageotaetets: Cee, resort, and assox;aaYed <br />aeau ~f' ~~; ae3v dtatt~e^ ar reaa€}xtt# ita~•e xtex:arred due{a~ 8tae 3-rev~emus near asctl rto rew cItacs ads to <br />tltg are p±ixras M1 x .xr's zsttaa :trre €xseessarr~. tPaett ao aesY ease 6s reaatirexi, arcvixied fleet Mite Cltterator sitai} state <br />dais iat the oatnatal ~eaaa.rt. P{ease nsatre a~err rsn trd~;ear~tefy frche;ecf :a~~~a tfatrt clenra~ defita~eates ez:ted incfLrl~s tf=e <br />nf~a.=z eleztae€?F f3zti}=~"xrf~icefr~m- r: ba+t#fer report <br />1Jiosian rGOrds indicate the €o?[ots-inz? p;:rmittee GGrtax:t information. P?ease verify and mat~•~ a:tu necessary <br />c!aarees: <br />?erfliitteY~ an:aGt: T aSErtrke 1Coellner <br />4'ea~nitteG :lame: L i~ :. Ready ?+~lix <br />r~.ddress: P.C.13ax2}S <br />efaxtan, CC? &Q73 i <br />?honc,i4umb~: i97fr)7?4-5}1~} <br />F•ax ~Setr:'t~r. ,97G) =74-5i i4 <br />i€ you har.~ additional comments an?~or i,-a€at-n:a2s'an E:a',ai should 'oe Erovix3ed to <he t~ivision, please ot~vide iY <br />4sir,~v c>r attach is to ibis i'orm aian~ aritlt your vrriften report one map. Ar,rtuai RcFart instntGtions are er,Glascd. <br />Sdt*naiure ofC'a:?tarate E3~ccr, flwnGr: or Ilesignc;. <br />f 5` <br />fate <br />