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1~ <br />~ 1 <br />ANNi7AL FEE and REPORT REQUEST <br />PERMTTTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />`'~S ne Cooper <br />~'M-1994-092 <br />Iron Mountain Road Gravel Pit <br />January 23, 2008 <br />~~~ ` .~ <br />~FEB r <br />o' ~ Z®®~ <br />~~ <br />M, o~~ecr;;,F~. <br />$$323.00 (Due on or before your anniversary date) <br />Fremont <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 rto 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 man. 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 Buff ce for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Shane Cooper <br />Permittee Name: Shane Cooper <br />Address: 4690 Cty. Rd. 27A, Ste. R <br />Cotopaxi, CO 81223 <br />Phone Number: (719) 942-3234 <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, Owner, or Designee <br />i/~ 31~~ <br />Date <br />M:~pEgMrr\MASTERDOCUMENTS~M-AF-04 <br />