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<br />01? <br /> •" <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: kent County <br />PERMIT NO.: vl`I-1983-177 <br />OPERATION NAME: Adams Pit <br />ANNIVERSARY DATE: November 2, 2008 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Bent <br /> <br />`-6CT 4 <br />Div,, r <br />According-to- C.R.S. 3-4:-32.5-116-pr C.R,S. 34-32-116, each -year, on the anniversary date of the permit an _ <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to 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 map 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 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 />Permittee Name: Bent County <br />Address: P.O. Box 350 <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />J-r,4s Er -N D-7-? C o IV 77t cam- C 44A Of G != <br />Permittee Contact: -Gafy ;a -r-p-a. e --p R u t961= <br />Las Animas, CO 81054 <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 />of Corporate Officer, Owrfer, or Designee <br />Date <br /> <br />M:\PERMIT\MASTERDOCUMENTS\M-AF-04