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T <br />ANNUAL FEE`and REPORT REOUEST <br />of Lamar <br />PERMITTEE NAME: AZ84-154 <br />PERMIT NO.: OPERATION NAME: Well Field Pit <br />ANNIVERSARY DATE: December 10, 2008 <br />RECEIVED <br />IAC 0 4 2008 <br />Division of Reclamation, <br />Mining and Safety <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Prowers <br />a /c <br />According to C.R.S. 34-32.5-1.16 or C.S. 34`32-116,_each_year, on_ the anniyersary 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 />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Patrick Mason <br />Permittee Name: City of Lamar <br />Address: 102 E Parmenter St <br /> Lamar, CO 81052-3239 <br />Phone Number: (719) 336-4495 <br />Fax Number: (719) 336-4404 <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 />osed. <br />Signature of Corporate Officer, Owner, or Designee <br />Moo .2 q, 2 o o V <br />Date <br />M: PERMIT\MASTERDOCLJMENTS\M-AF-04