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ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: City of Monte Vista <br />PERMIT NO.: M-1992-060 ? <br />OPERATION NAME: Lagoon Pit <br />ANNIVERSARY DATE: October 20, 2008 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Rio Grande <br />SEP 2 ?008 <br />Divislon 0i , "'C' <br />r:ng any i- - 1-1-ti <br />? tn' <br />Zm,f: <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 s a su mi IT' annual fey report arid=map-slt6;v?ing=t1 c-ex-tent-of-carrenf-4istdrbances-to-affecied_ - <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 vour revised written annual report and annual report may 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 vear'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 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: Don Van Wormer <br />Permittee Name: City of Monte Vista <br />Address: 4 Chico Camino <br />Monte Vista, CO 81144 <br />1A10 IVew dtS_lfk?^hdnCo?s 6!' <br />A-1C1&MCEY:01 hail.E Q Ct4tt-e4 dkr:.1?2 <br />At loku, 0-4 d 42 n 0 <br />JVL:..? Cvu.nse? ? ? ?`ci?o?J Yu?`1 <br />rnwP, <br />Phone Number: (719) 852-2692 <br />Fax Number: (719) 852-6172 <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 />closed. <br />v <br />Signature of Corporate Officer, Own , or Desi ee <br />°if?I -n <br />Date <br />M:\PERMIIIMASTERDOCUMENTS\NI-AF-04