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1. <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />' ?? <br />AN L FEE and REPORT REQUEST <br />IProwers County <br />1-1984-136 <br />Brann Pit <br />August 31, 2009 <br />RECEIVED <br />P'AUG 2 2009 <br />Division or vlc'darnou n <br />-? Mining and 37'; ",,, <br />$$323.00 (Due on or before your anniversary date) <br />Prowers <br /> <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'aiTd'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 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: Mark Dorenkamp <br />Permittee Name: <br />Address <br />Lamar, CO 81052 <br />Phone Number: <br />Fax Number: <br />Prowers County <br />109 E. Sherman St. <br />(719) 336-5536 <br />(719) 336-9633 <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 />- <br />Date <br />M-\PERMITMAS TERDOCUMENTS\M-AF-04