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F <br />WIC ,, 4d7 <br />ANNUAL FPE and REPORT REOUEST <br />PERMITTEE NAME: avid Goss <br />PERMIT NO.: ?M-1985-140 <br />OPERATION NAME: Goss Sand & Gravel <br />ANNIVERSARY DATE: January 24, 2009 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: El Paso <br />44C 0 5 2008 <br />Division of Declamation, <br />fit, Mining and afety <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 disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performee cTur?ing the-coming year, t e d-aTe'sTor the beginning T <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 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 necessarv. then no new man is reauired. 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: David D. Goss <br />Permittee Name: David Goss G.,* s <br />Address: 24040 Falcon Hwy <br />Cr?k ??-/?.tJ ?4 <br />Calhan, CO 80808-9156 - - - ?eSlo <br />Phone Number: (719) 683-2415 70 - (e 3 - 5/2 9s <br />Fax Number: 7(? - G 3 " 2G S/5- <br />If you have ad i ional mments and/or information that should be provided to the Division, please provide it <br />below or atta it to t 's form along with your written report and map. Annual Report instructions are enclosed. <br />Signature`OT Corporate Officer, Owner, or Designee <br />/Z 4 3/oy <br />Date