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PF A-- WT <br />ANNUAL FEE and REPORT REOUEST <br />?- <br />PERMITTEE NAME: Costilla County fXECF-1VF-0 <br />PERMIT NO.: M-1999-024 OCT -13 ZOO'f <br />OPERATION NAME: San Acacio Gravel Pit Division c+ ireclamation, <br />Mining and Safety <br />ANNIVERSARY DATE: October 4, 2009 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Costilla <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 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 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: Mathew L. Valdez <br />Permittee Name: <br />Address <br />Costilla County <br />352 Main St. <br />San Luis, CO 81152 <br />Phone Number: (719) 672-9109 <br />Fax Number: (719) 672-3003 <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 Designee <br />q 1.30 log <br />Date <br />M:IPERMr r\MASTERDOCUMENTS\M-AF-04