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~~ ~ R ~-~ ~~cEivE® <br />ANN-UAL FEE and REPORT REQUEST <br />.~~y ,IAN 17 2008 <br />PERMITTEE NAME: Rio Blanco County/~% Division or Keclamation, <br />PERMIT NO.: M-2004-038 ~./ Mining and Safety <br />OPERATION NAME: West Johnson Draw <br />ANNIVERSARY DATE: January 7, 2008 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Rio Blanco <br />_ __ _,__ According to ~)~S._3.~3~,.,~L.Lfzc~r_.C,R.S.~34_32.116,~eaoh_year, nn_ the annivc rcar3 a+P- ~' +1~~P,~„lt,_.axz <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 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 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: Rex-leper ~,J ~ ~ r . IV~.o /' L~.tJ <br />Permittee Name: Rio Blanco County <br />Address: 570 2nd St. <br />Meeker, CO 81641 <br />Phone Number: (970) 878-9590 <br />Fax Number: (970) 878-3396 <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 />gnature of Corporate fficer, Owner, or Designee <br />i~~~~~0 7 <br />Date <br />M: ~PERMIT~IASTERDOCUMENTS~M-AF-04 <br />