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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />0 f'N 7- <br />ANNUAL VEE a d REPORT REQUEST ECENED <br />Washington County <br />1M-1983-001 <br />Cecil 11-34-49 <br />May 16, 2009 <br />1-/APR -15 2000 <br />Division of ReCL2ma60n, <br />_ V blpft and Safety <br />$$323.00 (Due on or before your anniversary date) <br />Washington <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 accomplished to date and during the preceding year, new disturbances that are anticipated 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 chanp-es 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-sufficefor-a-written-report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: <br />Permittee Name: Washington County <br />Address: P.O. Box 32 <br />Phone Number: <br />Fax Number: <br />Anton, CO 80801 <br />(970) 383-2216 <br />(970) 383-2213 <br />DON RIEMENSCHNEIDER <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 />_ T <br />Signature of Corporate Officer, Owner, or Designee <br />e/id X) 9 <br />Date <br />M:\PERMIT\N4AS TERDOCUMENTS\N4-AF-04