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~~ ~RP1 <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~ Yuma County <br />j'Y1e.~'e(bu ~~ <br />~~30%~ <br /> <br />~' SEP ~ .; 2007 <br />Di ~sion o..~-~ia~rsuon, <br />Minim and SafE;y <br />~ 7g/, u' (Due oa or before your anniversary date) <br />Yuma <br />~f~ <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 yeaz, reclamation that will be performed during the coming yeaz, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour revised written annual report and annual report map to this form. The Anaaal <br />Report & Fee requirement is not met until we have received the following components: fee, resort, and <br />associated map. If no new disturbances or reclamation have occarred during the nrevions year and no <br />Operator shall state this in the Annual Report, Please note that an adequately labeled map that clearly <br />delineates and includes the above elements may su~cejor a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Paul Like <br />Permittee Name: Yuma County <br />Address; 1310 S. Blake St. <br />Phone Number: <br />Fax Number: <br />Wray, CO 80758 <br />(970)332-5718 <br />(970)332-3429 <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. Q - /J <br />Signature of Corporate Officer, Owner, or Designee <br />111 Ib`~ <br />Date <br />