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<br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />C <br />ANNU L FEE and REPORT REQUEST <br />Washington County <br />/4-2001-012 <br />Shook Gravel Pit 1 <br />May 31, 2009 <br /> <br /> <br />$$791.00 (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 shaa-11 submit fhe annual-fee, -d--report and map-showing the exert 6f -cut tent- d sturbances-1o a ected <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 vour 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 chanL-es to the previous vear'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: Jesse Stackhouse <br />Permittee Name: Washington County <br />Address: 150 Ash Avenue <br />Phone Number: <br />Fax Number: <br />ohs - <br />1-7 Cg'- Ll. <br />Akron, CO 80720 <br />(970) 345-2701 .700 k_z..?? ?- <br />(970) 345-2702 ellr? fQ oq-%-Q <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 />Officer, Owner, or Designee <br />Date <br />M:\PER vUT\MASTERDOCUMENTS\M-AF-04