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<br /> ANNUAL FEE and REPORT REOUEST <br /> V <br />PERMITTEE NAME: K Holsinger <br /> ? <br />PERMIT NO.: M-1980-052 <br />OPERATION NAME: Holsinger Gravel Pit <br />ANNIVERSARY DATE: April 23, 2009 <br />ANNUAL FEE DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY: Jackson <br />r, 1777 D <br />MAR 0 ,, 2009 V"-, <br />Division or i-eclamation, > " <br />Mining and Safety <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_ anti-cip-aW to Qccur -_ <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 your revised written annual report and annual report man 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 durine the previous year and no new chances to <br />the previous vear'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: Keith Holsinger <br />Permittee Name: K Holsinger <br />Address: P.O. Box 37 02-C <br />Walden, CO 80480 <br />Phone Number: (970) 723-4587 <br />Fax Number: (970) 723-4771 <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 enclosed. <br />Si ature of C&rjgrate Officer, per, or Designee <br />Date