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J <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Conejos County <br />M-1987-097 <br />La Florida Grav Pit <br />August 18, 2003 <br />RECEIVED <br />AU6 0 4 2003 <br />YfYision of Minerals and Geob~ y <br />$281.00 (Due on or before your anniversary date) <br />Conejos <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 Xnnr revised written annnal rennrt and annnal rennrt m,~ 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 permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Bob Lucero <br />Permittee Name: Conejos County <br />Address: 6683 County Rd. 13 <br />P O Box 157 <br />Conejos, CO 81129 <br />Phone Number: (719) 376-5772 <br />Fax Number: (719) 376-5661 <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 />of Corporate Officer, Own r, or Designee <br />Date <br />M:~PERM17Vv1ASTERD000MENTSVN-AF-04 <br />`• <br />