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<br />PERMITTE.E NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE <br />ANNUAL F'EE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Clyde and Marie Couch <br />M-1989-023 <br />Caliche School Pit <br />March 9, 2001 <br />$281.00 (Due on or before your anniversary date) <br />Logan <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 [he 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 />begipning of active operations, and the date active operations ceased for the year, ifany. ; a~i <br />Please attach your revised written annual report and annual resort map to this form. Please Hole that an <br />adequately labeled nrnp !ha! clearly delineates mrd inckrdes the above elen:erus may since for n written <br />report. <br />Division reoxds indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Pennittee Contact. Clyde Couch <br />Pennittee Name: Clyde and Marie Couch <br />Address: 1996 Co Rd # 34 <br />Sterling, CO 80751 <br />Phone Number: (970) 522-1239 <br />Fax Number: <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 />Signature of Corporate Officer or Owner <br />pate <br />M ~PERMI7lMA5TEF.D000t.~NTSN1-AF-01 <br />