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rvl ~- <br />v ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~~Shane Cooper <br />M-1994-092 <br />Iron Mountain Road Gravel Pit <br />January 23, 2007 <br />n/- os- v71 <br />RE~E~\/Ep <br />'SAN 0 5 2007 <br />/Bivistan of ~eetemetion, <br />Mining and Safety <br />$$281.00 (Due on or before your anniversary date) <br />Fremont <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 yeaz, 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 yeaz, if any. <br />Please attach vour revised written annual resort and annual report man to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred during the arevious year and no <br />new chanties to the previous year's map are necessary, then no new man is required, provided that the <br />Oaerator shall state this in the Annual Report, Please note that an adequately labeled map that clearly <br />delineates and includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Shane Cooper <br />Permittee Name: Shane Cooper <br />Address: 04690 Cty. Rd. 27A, Ste. R <br />Cotopaxi, CO 81223 <br />Phone Number: (719) 942-3234 <br />Fax Number: <br />5~ t`n C' <br />SAMC- <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 yyour written report and map. Annual Report instructions are / <br />enclosed. /~-~(' C f~ti~3 Crl KtZl~41v~,¢'S~r»l, yN cfGi'~~ <br />Signature of Corporate Officer, Owner; or Designee <br />~I~ ~ rS~ <br />Date <br />M:~PERMI'nMASTERDOCUMEN'C54M-AF-04 <br />