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j'• <br />~~~~~e91~i'T <br />NOV 15 2GG4 <br />fl~,:~__ _ ......_.. _ .. , <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Prowers County <br />M-1977-387 <br />Bates Pit <br />December 1, 2004 <br />$688.00 (Due on or before your anniversary date) <br />Prowers <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 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 ynnr revised written anneal red nrt and anneal re~nrt maw to thin form. Please note that an <br />adeq:iately labeled map that clearly delineates and includes the above elements may suffce 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: Tony Garcia <br />Permittee Name: Prowers County <br />Address: 109 E. Sherman St. <br />Phone Number: <br />Fax Number: <br />Lamar, CO 81052 <br />(719) 537-6631 <br />{719)537=6357 <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 />~~~~/ ~ w <br />S gnature of Corporate Officer, weer, or Designee <br />// ~-a t/ <br />Dat~ <br />MiPERMITNIASTERDOCUMENTSNr-AF-09 <br />