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ANNi7AL FEE and PORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />City of Lamar <br />/M-1987-078 <br />Lamar Park Gray Pit <br />June 24, 2009 <br />$$323.00 (Due on or before your anniversary date) <br />Prowers <br />D/c <br />JIC <br />WRAW <br />4UN 12-2009 <br />DMaim of RwiWa0on, <br />HAV and $d* <br />_Accordina to C_R-S. 34-3_.2.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an <br />operator sha-11cs11bm- i e annuar fee, a repof-dh map showing th"e 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 changes 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 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: Patrick Mason <br />Permittee Name: City of Lamar <br />Address: 102 E Parmenter St <br />!~ _ - `Lamar, -CO 8cW52 -- <br />Phone Number: (719) 336-4495 <br />Fax Number: (719) 336-4404 <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 />closed. <br />Signature of Corporate Officer, Owner, or Designee <br />-5-6-0 <br />Date <br />M: TERMITUvfAS TERDOCLTMENTS\N4-AF-04