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rco <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />AF ~,~/~~ <br />M~io Bassi and Josephine Bassi~-+ <br />!/M-2000-110 <br />North Farm Road Gravel Pit <br />September 17, 2005 <br />~//~~~t ; <br />~SEP i X005 <br />$688.00 (Due on or before your anniversary date) <br />Rio Grande <br />Accoroing io C:1Z~S-3=}=32:5=1'16 or C:R:S-34=32=I-I6-each-year-orcthe-anniversary-datc of she permit; an-operator- - - - - <br />shal] submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach xpnr revised written anneal report and anneal report main to this form- please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Pennittee Contact: Mario Bassi <br />Permittee Name: Mario Bassi and Josephine Bassi <br />Address: 2000 N. Farm Rd. <br />Monte Vista, CO 81144 <br />Phone Number: -(7T9j8S2=3225- - <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 enclosed. <br />~~~ ~~-~.. raw „rF ~ ~ <br />Signature of Corporate Officer, Owner, or Designee <br />~- G - o s' <br />Date <br />