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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~~ ~- RPM <br />ANNUAL FEE and REPORT REQUEST <br />~~.~ pa./~1~ <br />Prowers County <br />M-1977-387 ~/ <br />Bates Pit <br />December 1, 2007 <br />$$791.00 (Due on or before your anniversary date) <br />Prowers <br />®EC 13 ~®~~ ./ <br />®ivision of Reclarnapion, <br />Alining and 1'afety <br />According to C.R.S. 34-32.5-116 or C._R.S. 34_32_116.„each_year,-on_the-anni-versary date of-the p~rrriit;- an- <br />-- operator shall submit the annual fee, a report and map showing the extent of current disturbances to affectedi~ <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 report man to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred durinE the previous year and no <br />new changes to the previous year's map are necessary, then no new map is reauired, provided 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: Prowers County <br />Address: 109 E. Sherman St. <br />Lamar, CO 81052 <br />Phone Number: <br />Fax Number: <br />r /~~~~~ 1~r.~5~ <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 />~~6~ ~ ~ <br />Signature of Corporate Officer, C°)wner, or D ise gee <br />,~" ~ ~/.t <br />Date <br />M:~PERMITIMASTERDOCUMENTSUvi-AF-04 <br />