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aF *- Qf rr <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REOUEST <br />Moffat County <br />M-1978-007 `/ <br />Big Burn Pit No 17 <br />R F r, -7 P?/ ? <br />FED 1 S 1P99 <br />i t ??t7i?l?tiQf9, <br />®ivinion ni <br />Dining and 2aiaty <br />February 23, 2009 <br />$791.00 (Due on or before your anniversary date) <br />Moffat <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 a:aompti'sred-to date and during a preceding year; new-disturbances-that are an-icipated fo <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 may 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 chances to the previous year's may are necessary, then no new may 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 since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Billy E. Mack <br />Permittee Name <br />Address: <br />Moffat County <br />P.O. Box 667 <br />Craig, CO 81626 <br />Phone Number: (970) 824-3211 <br />Fax Number: (1970) 824-0356 <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 />Signature of - orate Officer, Owner, or Designee <br />1 )1 <br />i - I Ct <br />Date <br />M: PERMITIMASTERDOCUMENTS\Nl-AF-04