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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Agnacio Vasquez Sr <br />4-2000-089 <br />Perdue <br />October 4, 2008 <br />$323.00 (Due on or before your anniversary date) <br />Boulder <br />OK <br />X40 <br />;-'OCT 0 2008 <br />Division or .;????:,..? s r, <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 />- reclamation-accomplished-to.date-and-dur-ing-the -preceding year-,-new-disturbar?ees-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 your revised written annual report and annual report man 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 />theprevious year's map necessary, then no new map required, that the Operator shall state mapare necessa, then no new map is requiredprovided that the Operator shall state <br />this in the Annual 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 />Permittee Name <br />Ignacio Vasquez Sr <br />Ignacio Vasquez Sr <br />Address: P.O. Box 938 <br />Lyons, CO 80540 <br />Phone Number: (303) 823-5684 <br />Fax Number: <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 />Signa re of Corporate Office er, or Designee <br />IOlaIoT <br />Date