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,~~ ~ ~ P r- <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />~/ <br />N Colo Water Conservancy Dist. r/ <br />M-1981-085 ,~ <br />Riprap Quarry Area <br />July 21, 2009 <br />~~ <br />t/JUN ~~ 0 ~(~,:;~ <br />Minrnn and Safety <br />$791.00 (Due on or before your anniversary date) <br />Grand <br />-- According_to-C.R.S._.3.4.-3.2.5-_Ll-6_or_C.R.S._34-32=.1.1:6,-each ear,-on the~anniver-sary-date-of-the-per-wits-an- ----- _- <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />_ _land, reclamation accomplished t_o 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 man. If no new disturbances or reclamation have occurred during the previous year and no <br />new changes to the previous year's map are necessary, then no new map is reauired. 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: Jim Struble <br />Permittee Name: N Colo Water Conservancy Dist. <br />Address: 220 Water Avenue <br />Phone Number: <br />Fax Number: <br />Berthoud, CO 80513 <br />(970)532-7700 <br />(970)532-0942 <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 />Si r of C o fficer, Owner, or Designee <br />Date <br />M:~PERMIT~MASTERDOCUMENTS~Iv1-AF-04 <br />