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PP ?- R(?'-' <br /> ANNUAL FEE and <br />EPORT REOUEST <br /> (R <br />PERMITTEE NAME: Jack Clark Jr. <br />PERMIT NO.: M-2005-065 c/ <br />OPERATION NAME: Upper Animas Sand and Gravel Pit <br />ANNIVERSARY DATE: December 8, 2008 <br />ANNUAL FEE DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY: San Juan <br />Noll `I i7 2006 <br />Divisior, c,' , cacramation, <br />Mining and Safety <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-during- the- preceding- year;-new-distur-bances--that are-anticipated-to-occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning of <br />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 map. <br />If no new disturbances or reclamation have occurred durine the previous vear and no new chances to the <br />previous year's map are necessary, then no new map is required, provided that the Operator shall state this <br />in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the above <br />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: Jack Clark Jr <br />Permittee Name: Jack Clark Jr. <br />Address: P.O. Box 767 <br />Silverton, CO 81433 <br />Phone Number: (970) 387-5243 <br />Fax Number: <br />If you have additional comments and/or information that should be provided to the Division, please provide it below <br />or attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />Si of Corporate Officer, r, O , or Designee <br />© <br />Date