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ANNUAL FEE and REPORT REQUEST <br />PERMIT"fEE NAME: <br />PERMTT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />Moffat County <br />M-1948-003 <br />Raftopoulos PIt #I <br />April 28, 2006 <br />$688.00 (Due on or before your anniversary date) <br />Moffat <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 aze anticipated to <br />occur during the upcoming yeaz, reclamation that will be performed during the coming yeaz, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please note that an <br />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 />Pennittee Contact: Billy E. Mack <br />Permittee Name: Moffat County <br />Address: P.O. Box 667 <br />Phone Number: <br />Craig, CO 81626 <br />(970)824-3211 <br />Fax Number: (970) 824-0356 <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 or Owner <br />Date <br />