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Rip $,, Re 3-- <br />ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME:. <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Lake County <br />M-1977-459 <br />Lake County Grav Pit <br />July 8, 2009 <br />RECEIVED <br />v JUL 012009 <br />Division of Reclamation, <br />Mining and Safety <br />$791.00 (Due on or before your anniversary date) <br />Lake <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 man to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated may. If no new disturbances or reclamation have occurred durin the revious 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: Brad Palmer <br />Permittee Name: Lake County <br />Address: Road and Bridge <br />P.O. Box 952 <br />Leadville, CO 80461 <br />Phone Number: (719) 486-0259 <br />Fax Number: (719) 486-8479 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it/ta, this form along with your written report and map. Annual Report instructions are <br />S <br />Owner, or Designee <br />o9l' <br />Date <br />M:SPERM rMASTERDOCUMENTSIM-AF-04