2009-07-27_REPORT - M1984043

• Permit No: M1984043
• IBM Index Class Name: REPORT
• Doc Date: 7/27/2009
• Doc Name: Annual Fee/Report/Map
• From: Pelino, Inc.
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE
ANNUAL FEE DUE:
COUNTY:
ANNUAL FEE and REPORT REOUEST
Pelino, Inc.
M-1984-043 r""
Jesse Lee
July 25, 2009
$791.00 (Due on or before your anniversary date)
Chaffee
RECEIVED
JUL 2 7 200g
Division of Reclamation,
Mining and Safety
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 operator
shall submit the annual fee, a report and map showing the extent of current disturbances to affected land,
reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur
_ `duriirg tht-ap-coming-year, reclamation-thatcwili-be-p-erformedziuring-the`cisinin-gTeaT, the dates-for tiieb-egiriing - -
of active operations, and the date active operations ceased for the year, if any.
Please attach your revised written annual report and annual report map to this form. The Annual Report
& Fee requirement is not met until we have received the following components: fee, report, and associated
map. If no new disturbances or reclamation have occurred during the previous year and no new changes to
the previous year's map are necessary, then no new map is required, provided that the Operator shall state
this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the
above elements may suffice for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Scott Pelino
Permittee Name: Pelino, Inc.
Address: P.O. Box 5049 '
33551 CR. 361

Phone Number: [phone].
Fax Number: [phone] L q '617S If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are enclosed.

of Corporate Officer, Owner, or Designee