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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNTiAi. FF.F and RF.P<1RT RFOfiFST <br />Rio Grande County <br />M-1987-019 <br />South Fork Pit <br />RECD;` "~ °® <br />MAR 13 6:3D5 <br />March 25, 2005 Division of Minerals s..- , ,oiopy <br />$281.00 (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, 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 ynnr revised written annnal rr~ nrt and anmral re nrt m n to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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: Lawrence "Buddy" Shaver <br />Permittee Name: Rio Grande County <br />Address: 168 N. Washington <br /> Monte Vista, CO 81144 <br /> <br />Phone Number: i <br />(719) 852-4781 <br />Fax Number: (719) 852-0305 <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 />Srgnature of Corporate Officer, Owner, or Designee <br />,~-~/.~~ <br />Date <br />M:NERMITUTASTERDOCUM ENTSUI-AF-04 <br />