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<br />r <br />?F #- (?? 1' <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REOUEST <br />Custer County <br />M-1995-026 <br />Gravel Pit M-093 <br />August 24, 2009 <br />AUG 0 5 2009 <br />t/ Divis <br />Mihin9 ahecl <br />d S?? °n. <br />$791.00 (Due on or before your anniversary date) <br />Custer <br />--- ----Tc-cerding-to-G,RrS.--3A 3-.2.5=116-or-GrR.S.-34=32=1 L6, each_year,_on__the_anniversary_date-oLthe pernit,_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 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 vear'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 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: David Trujillo <br />Permittee Name: Custer County X)a e-X 4 rm <br />Address: P.O. Box 1669 <br />Westcliffe, CO 81252 <br />Phone Number: (719) 783-2281 <br />Fax Number: (719) 783-0391 <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 />Signature of Corporate Off er, Owner, or Designee <br />LA, lr- ©t <br />Dat 0- <br />M: \PERN4rIVvIASTERDOCLTMENTS\M-AF-04