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ANNiiAi, FF.F and RF,Pt1RT RF.f7iTFST <br />~~~~~~lr <br />PERMITTEE NAME: Mario Bassi and Josephine Bassi <br /> SEP 0 9 2004 <br />PERMIT NO.: M-2000-110 <br />OPERATION NAME: North Farm Road Gravel Pit Oicision of Ilginzeats M ~;n!o~y <br />ANNNERSARY DATE: September 17, 2004 <br />ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br />COUNTY: 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 operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation_accompliched-to date-and-during-the-preceding-year,-new-disturbances-that-are-anticipated'to occur-----'-_I <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written anneal report and anneal report man trc this form. Please note [hat an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Pennittee Contact: Mario Bassi <br />Permittee Name: Mario Bassi and Josephine Bassi <br />Address: 2000 N. Farm Rd. <br />Monte Vista, CO 81144 <br />Phone Number: (719) 852-3225 <br />Fax Number: <br />If you have additional comments and/or information fhat 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 enclosed. <br />Signature of Corporate Officer, Owner, or Designee <br />2 ~- O <br />Date <br />