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i <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE; <br />ANNUAL FEE DUE: <br />COUNTY: <br />~~~ ~ <br />'/ANNTiAT. FF.F, and RF.Pt7RT RF.I)T1F.ST <br />~ Park Couuty <br />/M-1980-251 <br />Ansley Flat Pit <br />April 1, 2006 <br />~CC~fV~® <br />G~ hi(af~ 2 , Z~06 <br />r/ Divm~on of ~J~inorals and Gcolony <br />$281.00 (Due on or before your anniversary date) <br />Park <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 cun•ent 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 yeaz, if any. <br />Please attach xpnr revised written nnmial report and annual r art map, 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: David Kintz <br />Permittee Name: Pazk County <br />Address: P.O. Box 147 <br />Fairplay, CO 80440 <br />Phone Number: (719) 836` <br />Fax Number: (719) 836-4275 <br />c%//y! Lives/ <br />V <br />y~2l.33 i% <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 />i <br />Signa e o C rporate O ice , er, or Designee <br />~/~/06 <br />Date <br />M:~PERMITMASTERDOCUMENTS4M-AF-0O <br />