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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNiJAL FEE DUE: <br />COUNTY: <br />~/h2 <br />r~~~~ <br />AL FLEE and REPORT REQUEST <br />/dark County <br />.~M-1980-251 <br />Ansley Flat Pit <br />April 1, 2008 <br />$$323.00 (Due on or before your anniversary date) <br />Park <br />~~ <br />~~ ~ ~ ~~~~ <br />~ivrs,~,. <br />_, :t~~e <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 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 man 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: Jim Linn <br />Permittee Name: Park County <br />Address: P.O. Box 147 <br />Fairplay, CO 80440 <br />Phone Number: (719) 836-4283 <br />Fax Number: (719) 836-4275 <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 />enclo <br />Ignature of Corporate Offce ,Owner, or Designee <br />.~~~/~ ~ <br />Date <br />M:~PERMITVvIASTERDOCUMENTS~ivi-AF-04 <br />