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4w-: *- kP <br /> ANNUAL FEE and REPORT REQUEST <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: Montezuma County <br />M-1999-077 <br />OPERATION NAME: Ormiston Gravel Pit <br />ANNIVERSARY DATE: October 25, 2009 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Dolores <br />SEP f <br />Division <br />°f r•??la;na, A <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 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 may 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: Lloyd Everett <br />Permittee Name: Montezuma County <br />Address: 1680NorthgIighvm?-145 i?6,4-L boar?-:s uQbAi- <br /> Cortez, CO 81321 <br />Phone Number: (970) 565-8666 <br />Fax Number: (970) 565-8252 <br />If you have additional comments and/or information that should provided to the Division, please provide it <br />below or attach it to this form along with your written re rt and map. Annual Report instructions are <br />enclosed. <br />Signa e of Corporate Officer, Owner, or Designee <br />D to <br /> <br />Q? V-6-\\ l , ? -'c <br />MAPERNMAMASTERD0CUMENTSW-AF-04