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,L ~ 1 v D 'S <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />,,, , <br />Malouff Construction Iuc. <br />M-1982-033 <br />Malouff Pit <br />October 8, 2005 <br />$688.00 (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 operator <br />shall 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 ynnr revised written anneal report and anneal rennrf main M this fnrm_ Please note that an <br />adequately labeled map that clearly 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: Stephen Malouff <br />Permittee Name: Malouff Construction Inc. <br />Address: 6496 Malouff Rd. <br />Alamosa, CO 81101 <br />Phone Number: (719) 589-4198 <br />Fax Number: (719) 589-2112 <br />~D ~, ~~_ <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 />/ ~~ <br />Signa of Corporate Officer, O er, or Designee <br />!2 -3' -DS~ <br />Date <br />