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ANNUAL FEE and REPORT REQUEST <br />PERMITI'EE NAME: <br />PERMTI' NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Conejos County <br />M-1987-097 <br />La Florida Grav Pit <br />August 18, 2002 <br />Divis ~ ; Gem <br />$281.00 (Due on or before your anniversary date) <br />Conejos <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 />land, reclamation accomplished to date and during the preceding year, new disturbances that are 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 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 suffice for a wrinen <br />report. <br />Division records indicate the Following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Bob Lucero <br />Permittee Name: Conejos County <br />Address: 6683 County Rd. 13 <br />P O Box 157 <br />Conejos, CO 81129 <br />Phone Number: (719) 376-5772 <br />Fax Number: (719) 376-5661 <br />RECEIVED <br />JUL 2 5.2002 <br />R' ' ...,_ <br />Oivlslon of Minerals atlDru°aiogy <br />}` ' ) <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 />. / ~~ c[, cr..~ <br />Signature of Corporate Officer or Owner <br />-:23- o <br />Date <br />M?PERM ^~MASTERDOCU M ENTSVN-AF-04 <br />