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~, h~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~/ ANNUAL FEE and REPORT REQUEST <br />t/ ontezuma County <br />t/ M-1978-107 <br />Tozer Pit <br />November 2, 2006 <br />sM ~z <br />td ~-0~ <br />'~ , <br />~ ocT ~ a Zaos <br />ivision ofa d Safety n <br />6Aining <br />$688.00 (Due on or before your anniversary date) <br />Montezuma <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116' each ear, on the anniversary date of the_pe_nnit, 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 vour revised written annual report and annual reuort mao to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated mao. If no new disturbances or reclamation have occurred during the previous vear and no <br />new chances to the previous year's mao are necessary. then no new mao is required, arovided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />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 />Permittee Contact: <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Lloyd Everett <br />Montezuma County <br />1680 Hwy. 145 <br />Cortez, CO 81321 <br />(970)565-8666 <br />(970)565-8252 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below r attach it to this form along with your written report and map. Annual Report instructions are <br />encl d. ~ <br />tgna o Corporate Officer, Owner, or Designee <br />to / y ~c5 ~o ~ ~ ~~ ~.~c~u.l.~~-, <br />Date <br /> <br />M:IPERMITVv1ASTERDOC[1MEMSU7-AF-04 <br />