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~ n <br />.. <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Forest Lakes Metro District <br />M-1981-158 <br />Forest Lakes Pit #1 <br />January 26, 2004 <br />~~FEtVED <br />2004 <br />~lviaion of Minerals m GaslspY <br />$281.00 (Due on or before your anniversary date) <br />La Plata ~ S <br />` ~~CJ <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,-rcclamation aceomplished-to date and during-thc-precedingyear,-new disturbaneerthat-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 rennrt and anneal rennrt mare to this form. please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written <br />report. <br />Division records indicate the following petmittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Dale Kortz <br />Permittee Name: Forest Lakes Metro District <br />Address: P. O. Box 440 <br />Bayfield, CO 8 1 1 22-0440 <br />---Phane-Number:-(990)-$84 2925 <br />Fax Number: (970) 884-0305 <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 />Irk o~ Corporate Offi~gr, Owner, or Designee <br />/S~/0 <br />M iPERM IT\MASTERDOCUM ENTSN-I-AF-04 <br />