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0t <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />'Ov r <br />ANA'LFEE and REPORT REQUEST <br />1,4 <br />ent County <br />B <br />.M-1991-086 <br />Earl-Hoffman-Reyher <br />October 3, 2008 <br />'?i`\. 1'I!f:° <br />I ?" <br />17 <br />A_? , / ? <br />''SEEP 2 ? 2008 <br />-/t7 Mininc, 2nd Safety <br />$$791.00 (Due on or before your anniversary date) <br />Bent <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 repo`rf a`lcn map s1-cowing the exfent of current=disturbances ? o-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 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 year's may are necessary, then no new may 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 />C /-?Ahf'Cp <br />n1-7 <br />Permittee Contact: , - <br />Permittee Name <br />Address: <br />Bent County <br />P.O. Box 350 <br />Las Animas, CO 81054-0350 <br />Phone Number: (719) 456-2223 <br />Fax Number: (719) 456-0375 <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, wrier, or gnee <br />C:) ! B - -n-o v-a <br />Date <br />M:\PERMIT\MASTERDOCUMENTS\M-AF-04