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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUN"I'Y: <br />ANNTiAT. FFF, and RFP(TRT RFOTTF;4T <br />Elbert County <br />M-2001-056 <br />Belveal Gravel Pit <br />November 9, 2004 <br />~~~~~~~D <br />®CT 1 ~, 2004 <br />Division of h7inasais & GoolOgy <br />$281.00 (Due on or before your anniversary date) <br />Elbert <br />According to C.R.S. 34-32.5-116 or C.RS. 34-32-116, each year, on the anniversary date of the permit, an <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that aze anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach ynnr revised written annnal regyt and anm~al re~~ort maw to this form. Please note that an <br />adequately labeled map that clearly deli~aeates and includes the above elements may suffice for a written <br />report. <br />Division records indicate the following perrruttee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Tim Sheridan <br />Permittee Name: Elbert County <br />Address: 809 Ute Ave <br />Simla, CO 80835 <br />Phone Number: (719) 541-2268 <br />Fax Number: (719) 541-2826 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />Signature of C or O cer, Owner, or Designee <br />~~. /~. ~~ <br />Date <br />M:~PERMTTVdA$TERDOCUMENTSVrI-AF-04 <br />