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.~ a <br /> <br />RECEIVED <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />City of Monte Vista <br />M-1992-060 <br />Lagoon Pit <br />October 20, 2002 <br />NOV 15 2x02 <br />Division of Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Rio Grande <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_suhmit_the_annual.fee._a_report_and_ma~shQwing 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 [hat 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 your revised written annual report and annual report map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a nvritten <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: n ~^a °n•°°Ta <br />Pennittee Name: City of Monte Vista <br />Address: 4 Chico Camino <br />Monte Vista, CO 81144 <br />~OVR ~~ /l~uFmE/ <br />- Phona-N;rmber:--(7-19)-832 2692 ___ __. __ _ __ _ __ - _ _ <br />Fax Number: (719) 852-6172 <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. Annua] Report instmctions are <br />enclosed. <br />O1 `r~.. ~'V~C, <br />tgnature of Corporate Office er, or Designee <br />r~/~/v <br />Date <br /> <br />MaPERMITN1ASTERDOCUMENTSiM-AF-b! <br />