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<br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: Wallace F. Burtis RECEIVED <br />PERMIT NO.: M-2001-070 AUG 1 ? ?nnq <br />OPERATION NAME: Florence Pit Division of R-clamp lion, <br />ANNIVERSARY DATE: August 23, 2009 <br />ANNUAL FEE DUE: $$259.00 (Due on or before your anniversary date) <br />COUNTY: Teller <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 accomplis ed to ate an uring 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 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 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: Wallace F. Burtis <br />Permittee Name: Wallace F. Burtis <br />Address: 66 Dartmouth Ave. <br />Pueblo, CO 81005 <br />Phone Number: (719) 566-1669 <br />Fax Number: <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. rJ l <br />Signature of Corporate Officer, wner, or Designee <br />8--1/-o ? <br />Date <br />M:(PERMIT\MASTERDOCUMENTS/M-AF-02. DOC