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FEB-09-2009 12:55PM FROM-DIV RECLAMATION MINING 8 SAFETY +3038326106 <br />Jr- , <br />.'i. FF,E a RE RJEOUEST <br />I PERMITTEE NAME: 'f?' H !yoke Gun Club <br />PERMIT NO.: Z-1977-075 <br />OPERATION NAME: Holyoke Gun Club Pit <br />ANNIVERSARY DATE. September 27, 2008 <br />T-079 P-002/002 F-946 <br />ecs <br />R'Fcr'lvm) <br />Division o6 i 74;,jatlA?p <br />Mining Cad Safety , <br />ANNUAL FEE. DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY- Phillips <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 performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach our revised written annual report and annual report ma to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee re o and associated <br />mao. If no new disturbances or reclamation have occurred during the Previous vear and no new chap es to <br />the previous year's man are_necessaEj, then no new map is required 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 permitter contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact. &X 9ershf le dt <br />Permittee Name: =Heiyoe-duin- <br />-Club <br />Address: 45 <br />SS ?f ?h?etN-a <br />5? 7v? a EF <br />lioIyoke, CO 80734-9507 <br />Phone Number: _ ) 854-364 <br />Fax Number: <br />cl <br />97u ja q -3 ) q q7?? <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 Repon instructions are enclosed. <br />Signature of Corporate Officer, Owner, or Designee <br /> <br />Date