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~~ ~ ~~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REP/O.R/T REQUEST <br />City of Monte Vist <br />M-1992-060 <br />Lagoon Pit <br />October 20, 2007 <br /> <br />RECEx~gF'~ / <br />OCT 2 [ ~~=E / ~ <br />DNis~'b ~ and Sateb n <br />$$323.00 (Due on or before your anniversary date) <br />Rio Grande <br />- -- According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116,_eaclLye~r nn th___„P a~nnive~afy 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 your revised written annual report and annual report map 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 previous veer and no <br />new chances to the previous year's map are necessary. then no new map is required, provided that the <br />Operator shall state this in the Annual Report. Please node that an adequately labeled map that clearly <br />delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Don Van Wormer <br />Permittee Name: City of Monte Vista <br />Address: 4 Chico Camino <br />Monte Vista, CO 81144 <br />Phone Number: (719) 852-2692 <br />Fax Number: (719) 852-6172 <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 />(\ r ` `,~ <br />Signature of Corporate Officer, Owner, or Designee <br />Dale <br />~/p l~/ew d;s>u./br<gces v/' /ec/4Mct~ia~1 h~/.,~ ©~~ur~{d du~;~ac '~`~ <br />{~reil~ ~ ws year <br />M:~PERMITUMASTERDOCUMENTSNI-AF-04 <br />