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PA <br />a C--y <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />/4? " r`? T- <br />ANNUAL FEt and REPORT REQUEST <br />ACity of Golden <br />V4-1977-534 <br />Empire Pit <br />January 30, 2009 <br />mcawo <br />?,AN 0 7 2000 <br />Division Mining Oland Sa tY n? <br />$$791.00 (Due on or before your anniversary date) <br />Clear Creek <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 <br />- - - operator-shall-submit the-annual fee, a report_and map _showing the extent of current disturbances to affected <br />land; reclamation accoriiplished-to date and-duririg the preceding-year,-new-dsturbance-`sha a? re antic ated 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: Dan Hartman <br />Permittee Name: City of Golden <br />Address <br />Phone Number: <br />Fax Number <br />Director of Public Works <br />911 Tenth St. <br />Golden, CO 80401 <br />(303) 384-8000 <br />(303) 384-8161 <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 />/& -'' /..- ,C. <br />Signature of Corporate Officer, Owner, or Designee <br />/.? -aI- 08 <br />Date <br />M-\PERM I T\MASTE RDOC UMENTS\M-AF-04