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0 III IIIIIIIIIIIII III <br /> 999 <br /> ANNUAL FEE and REPORT REQUEST <br /> RECEIVED <br /> PERMITTEE NAME: Andrews Sand & Gravel APR 0 9 2001 <br /> PERMIT NO.: M-1983-073 <br /> OPERATION NAME: Andrews S & G No 1 piyWOm1t11Em�T <br /> ANNIVERSARY DATE: May 25,2001 <br /> ANNUAL FEE DUE: $225.00 (Due on or before your anniversary date) <br /> COUNTY: Kit Carson <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 man 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: Jerry E. Andrews ),�eq (ln[� 'Vz�t -V- <br /> Perin ittee Name: Andrews Sand &Gravel <br /> Address: 166 8th St. <br /> Burlington, CO 80807 <br /> Phone Number: (719) 346-881 1 <br /> Fax Number: (719) 346-5037 <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 a of rporate Officer or Owner <br /> Date <br /> M TERMnV.1ASTERDOCUMENTS\M-AF-01 <br />