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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUA FEE and REPORT RE0UEST <br />WI'Gail C. Allen and Millie J. Allen <br />t -2000-050 <br />Broken Spear Pit <br />October 2, 2008 <br />',v 14so <br />S 3 ? p Z00% <br />pivislon o' `mod Sa n, <br />VV.in1n9 an <br />$$323.00 (Due on or before your anniversary date) <br />Lincoln <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 />r- eclamation ;Eci coy i hed-tv-date-and-during-the-pre-ceding-y.ear_new dis <br />.t rbances 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 ceased for the year, if any. <br />Please attach vour revised written annual report and annual report map 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 during 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: <br />M,?,/ k 'r /3'a, ? <br />Permittee Name: Gail C. Allen and Millie J. Allen <br />Address: P.O. Box 38 <br />Phone Number: <br />Fax Number: <br />Limon, CO 80828 <br />(719) 544-3358 <br />(719) 743-2809 <br />(21.1 ) -) qD-23 3 <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 />0?' '&'c /r-:- <br />Signature of Corporate Officer, Owner, or Designee <br />?-_ q- ohs <br />Date