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n>~ <br />i~ bh <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />j/ ANNTTAT. FF.F, and RF.PnRT RF.t7TIF.ST <br />v' Lincoln County <br />~M-1978-080 <br />Elmer Stone Gravel Pit <br />May 24, 2006 <br />$281.00 (Due on or before your anniversary date) <br />Lincoln <br />R~~EIVED <br />~ MAY 0 22006 <br />t/Division pt tyx~rghMdOwIoBY <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-year,-reclamation~thaCwill-be performed during the coming year, the dates foi tl e <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach ymrr revised written annual res nrt and anmral report ma+ to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice 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: Don Blake <br />Permittee Name: Lincoln County <br />Address: P.O. Box 39 <br />103 3rd Ave. <br />Hugo, CO 80821 <br />Phone Number: (719) 743-2337 <br />Fax Number: (719) 743-2815 <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 />__(~t~ ~~-!~- <br />Signature of Corporate Officer, Owner, or Designee <br />o~ ©r7- 0,6 <br />Date <br />M:IPERMInMASTERD000MENTSM-AF-04 <br />