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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />F , 0 '__ <br />4 " / 400 ( <br />ANNUAL FEE'and REPORT REQUEST <br />k* wa County <br />1983-116 <br />Gentz Gravel Pit <br />August 25, 2009 <br />RECEIVED <br />/JUL 16 2009 <br />Division of Kedamation, <br />Mining and Safety <br />$$323.00 (Due on or before your anniversary date) <br />Prowers <br />?(e <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 subinit-the annual fee, a -report and map show=ing 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 changes to the previous year's may 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 suff ce for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Rodney Hopkins <br />Permittee Name: Kiowa County <br />Address: P.O. Box 100 <br />Eads, CO 81036 <br />Phone Number: (719) 438-5810 <br />Fax Number: (719) 438-5327 <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 />6Q?_.? <br />Signature of Corp rate icer, Owner, or Designee <br />Date <br />M:IPERMITIMAS TERDOCUMENTS\M-AF-04