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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Silver Mountain Preserve, Inc. <br />M-1992-003 <br />Willis Pit <br />February 7, 2005 <br />'ai~n ;o-,,, ~,~ ..... <br />$281.00 (Due on or before your anniversary date) <br />Huerfano <br />~~ <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 I <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />-reclamation-accomplished-to-date-and-during-tlte-preceding-year~v~disturbances~that-~e`anh`c~p`ated Co 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 annual tenor[ and annual re nn rt m~ to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Travis R. Crawford <br />Permittee Name: Silver Mountain Preserve, Inc. <br />Address: 11850 CR 520 <br /> La Veta, CO 81055 <br />Phone Number: (719) 742-3971 <br />Fax Number: (719) 868-2416 <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 enclosed. <br />Signature of Corporate Officer, Ow , or Designee <br />% -/~- 0~ <br />Date <br />