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<br />~~~~e~ <br />ANNUAL FEE and REPORT REQUEST <br />V <br />PERMITTEE NAME: Costilla County/ <br />PERMIT NO.: M-1980-233 v <br />OPERATION NAME: Costilla <br />ANNIVERSARY DATE: December 11, 2007 <br />ANN-UAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Costilla <br />~~!~~~~ <br />DEC 17 2007 /~v <br />a <br />Division of Raclasnatipn,/ <br />Mining and ~ agety <br />A~cordinQ to C' R_.S. 34-~~.5-11F, or C.R..S. 34-3~-_116, eachyyear~_on the_anniversary,date o£the,;permit~_;ln._ <br />operator shall submit the annual tee, a report ana -map showing tale extent or curretl~ uisturuar:ees ~o ai~c~ce~f~ ~ <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 your 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 during the previous year and no <br />new changes to the previous year's man are necessary. then no new man 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: 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: <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, O er, or Designee <br />a /~ b l~ <br />Date <br />M:~PERMIT~IvIASTERDOCUMENTSVvt-AF-04 <br />