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<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 />David Goss <br />~ M-1985-140 <br />Goss Sand & Gravel <br />January 24, 2008 <br />$$323.00 (Due on or before your anniversary date) <br />El Paso <br />~~ <br />,MAR 1 1 ~~~~ <br />Division do r~~~w„tlv~,~,,, <br />Mining and ~~fety <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 operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations cease or t e year, r any. - -- <br />Please attach your revised written annual report and annual report man to this form The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred durin the previous year and no new changes to <br />the previous year's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: David Goss <br />Permittee Name: David Goss <br />Address: Rt 2 6759 Ellicott Hwy <br />Calhan, CO 80808 <br />Phone Number: (719) 683-2415 <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 enclosed. <br />>~ <br />Signature of Corporate Officer, Owner, or Designee <br />~(-ccT~y ~ <br />Date <br />