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tp- +- 12 PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Conejos County <br />M-1987-097 11L'? <br />La Florida Gravel Pit <br />August 18, 2009 <br />RECENED <br />?AUG 0 6 2009 <br />Division of Reclamslion, <br />Milling and Safety <br />$323.00 (Due on or before your anniversary date) <br />Conejos <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-disturbanees-to-af€eete' <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 vour revised written annual renort 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 map. If no new disturbances or reclamation have occurred durinE the Previous year and no <br />new chances to the previous vear's man are necessarv, 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 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: Bob Lucero?,'??=? 15 $'? ?C?co, C.cild ?> <br />Permittee Name: Conejos County <br />Address: P.O. Box 157 <br />6683 County Rd 13 <br />Conejos, CO 81129 <br />Phone Number: <br />Fax Number: <br />(719) 376-5772 <br />(719) 376-5661 <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 Officer, Owner, or Designee <br />I- t- 6!f <br />Date <br />M:\PERMIT\MASTERDOCUMENTS\NI-AF-04