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IV1~7~ <br />rGo <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE; <br />COUNTY: <br />v~ ANNi1Ai, FF.F, and REPORT RF.OiTF.ST <br />~/Wilbur F. Benham <br />V M-1984-039 <br />Toltec No 2 <br />Apri125, 2006 <br />~~~,~Eo <br />q/Oivi6Yan otMiaBrela and 0e~ <br />$225.00 (Due on or before your anniversary date) <br />San Juan <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each yeaz, 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 />rand i~ctanration acaatnplishzd'tsd-ate a~iii-dw`rin~tn`~iecedine year, new Risturbances a are anncipateti 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 aftachwmrr revised written anmral report and annnal repnH man fn this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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: Wilbur F. Benham <br />Permittee Name: Wilbur F. Benham <br />Address: 10195 S. Houghton Rd., #107 <br />Tucson, AZ &5747 <br />;!/oP.~ ~ ,',J ~ art 7~f~.C7l~ mod--' <br />>~ ~•et ~ cG L" , ~ ,G%~ m" r~z <br />i~ <br />~6~A~~ R ~ i ~ ~n/ii~ <br />s <br />i <br />Phone i~,~amber: {520) 574=1016--- ^-^ - - - - ------~~~,- J(~a //~~J ~t5/ur~ ~,DGer <br />Fax Number: J <br />~% <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 />Signature of Corporate Officer, Owner, or Designee <br />6.</ ~ / o ~ <br />Date ~ <br />~~-ci~l !~~C^G=-' ~ - ' 1, <br />~~~ a e~ ~- <br />~'~' ~ a <br />M:IPERMITMASTBRDOCUMENLS/M-AF-02.DOC <br />~i!I ~~, < <br />~- 9~ <br />