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~~z <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />'',iefferson County <br />M-1977-245 <br />Pine Junction Pit <br /> <br />-~ ° ~'~~~ <br />~4~ ~ ~ ~®® <br />ivisrc~~ c,-. <br />Mini~tg ~~;~~ 1 ~fePy on. <br />January 31, 2008 <br />$$791.00 (Due on or before your anniversary date) <br />Jefferson <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-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 map 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 map are necessary, then no new map is required, 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: Paul G. Rice <br />Permittee Name: Jefferson County <br />Address: 21401 Golden Gate Canyon Road <br />Golden, CO 80403-8108 <br />Phone Number: (303) 271-5205 <br />Fax Number: (303) 271-5222 <br />Ov/S ~~l ~'o~ <br />Ssz.~. -r <br />S~~ <br />j'ttr~,..~. <br />S a~-~ -~ <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 />~z~/~ <br />Date <br />M:IPERMITVVIASTERDOCUMENTS~M-AF-04 <br />