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<br />~---" ~- <br />~ANNTiAT, FF.F. and REPORT RF,OTTFST R~CEI,JED <br />PERMITTEE NAME: t/ Costilla County ~ ~V~ 0 5 ~~ <br />PERMIT NO.: ~M-1994-103 t/pivieioa of Minerals end Geology <br />OPERATION NAME: Sierra Grande Site <br />ANNNERSARY DATE: June 6, 2006 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Costilla <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'anndal'fee, a report and map showing the extent of current disturbances to affected <br />__ _ _ land, reclamation, accomplish_ed_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 ymrr revised written annual rernrt and anmral reFnrt mar to this form. Please note that an <br />adequately Labeled map that clearly delineates and includes the above elements may suffice 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: Mathew Valdez <br />Permittee Name: Costilla County <br />Address: P.O. Box 130 <br />San Luis, CO 81152 <br />Phone Number: (719) 672-9109 - ` <br />Fax Number: (719) 672-3003 <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 />U~~ <br />Signature of Corporate Officer, Owner Designee <br />sl~i /off <br />Date <br />M:~PERMITNrASTERDOCUMENTS~M-AF-04 <br />