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:~ - Y <br />t I V <br />ANNUAL FEE and REPORT REQUEST <br />RECEIVED <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Kiowa County <br />M-1985-173 <br />Rother Gravel Pit <br />February 3, 2002 <br />FEB 0 4 2002 <br />Division of Minerals and Geology <br />$688.00 (Due on or before your anniversary date) <br />Kiowa <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'durmg the preceding year, new"distu~ances thai ar`e anuc7pa[ed 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 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 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: ~4ik~Sgiitter <br />Permittee Name: Kiowa County <br />Address: P.O. Box 100 <br />Eads, CO 81036 <br />Phone Number: (719) 438-5810 _ _ _ _ <br />Fax Number: (719) 438-5327 <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 />Si azure of Corp r e Officer Owner <br />~~/~~ <br />Datc <br />M ~PERMITIMASTERDOCUMENTSVN-AF-05 <br />