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cK #Fol 3 0 0 <br /> • <br /> III IIIIIIIII IIII III <br /> 999 <br /> ANNUAL FEE and REPORT REOUEST <br /> PERMITTEE NAME: Bent County REcEj VED <br /> PERMIT NO.: M-1983-177 OCT 13 2coo <br /> OPERATION NAME: Adams Pit 1jtvtstan of Minerals and GaologY <br /> ANNIVERSARY DATE: November 2,2000 <br /> ANNUAL FEE DUE: $281.00(Due on or before your anniversary date) <br /> COUNTY: Bent <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 your revised written annual report and annual report map to this form. Please note that an <br /> adequately labeled nrap that clearly delineates and includes the above elements may suffice 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: Virley Burkhalter <br /> Permittee Name: Bent County <br /> Address: P.O. Box 350 <br /> Las Animas, CO 81054 <br /> Phone Number: (719)456-2223 <br /> Fax Number: f77kh99WA"*79* 719-456-0375 <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 /> Signatu&Vof Corporate Officer or Owner <br /> /f9- - n7 .<en Pi <br /> Date <br /> ERD M\PERMRV.IA.S T OCUMEM'SN-AF-U/1 <br />