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~~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />;/ANNUAL FEE and REPORT REQUEST <br />/ Kiowa County <br />~-1991-075 <br />Barnes Pit <br />November 12, 2006 <br />L <br />~ ~ -z~6 <br />RIG~~~~~~ ~.© <br />>/ oc~ ~ ~ 1nn~ <br />~pivision ofa d Safety n <br />M~nin9 <br />$688.00 (Due on or before your anniversary date) <br />Kiowa <br />According !e G.R.S. 34-32.5-11b-or C.R.S: 3432-1-16,-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 vour 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 man. If no new disturbances or reclamation have occurred during the previous year and no <br />new chances to the previous year's map are necessary,then no new map is required, arovided that the <br />Operator 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: Allen W. Watts <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Kiowa County <br />P.O. Box 100 <br />Eads, CO 81036 <br />(719)438-5810 <br />(719) 43 ~~ <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 />/d.~-rti~ <br />Signa~ure of Corporate Officer, Owner, or Designee <br />/D ~/3~dlD <br />Date <br /> <br />M:~PERMITMASTERD000MENTSVvf-AF-0O <br />