REP00039 ‎(2)‎

ANNUAL FEE and REPORT REQUEST
PERMITTEE NAME: Valco - Rocky Ford Div RECEIVED
PERMIT NO.: M-1977-222 FEB 0 4 2004
OPERATION NAME: Rocky Ford South Pi[
Dinisian of Minerals&Geulop►'
ANNIVERSARY DATE: January 25, 2004
ANNUAL FEE DUE: $688.00(Due on or before your anniversary date)
COUNTY: Otero
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
shall-submit the annual fee, a report and map showing the extent of current disturbances to affected land,
reclamation-accomplished to date-and-during-the-preceding-year,-new-disturbances-that-are-anticipated-to-occur
during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning
of active operations, and the date active operations ceased for the year, if any.
Please attach yonr revised written annual report and annual report man to this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may suffice,lbr a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Wayne Adams
Permittee Name: Valco-Rocky Ford Div
Address: P. O. Box 550
Rocky Ford, CO 81067
Phone Number: [phone]
Fax Number: [phone]
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are enclosed.
elz ¢ C. K�
Signature of Corporate Officer, Owner, or Designee
Date
M:�PERM ITVMASTER DOCIJM ENTSIM-A F-01