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/SF- " T <br />ANNUAL FEE and REPORT REQUEST <br />owers County <br />PERMITTEE NAME: P;MF-2002-062 <br />PERMIT NO.: OPERATION NAME: Davis Pit <br />ANNIVERSARY DATE: October 16, 2009 <br />o/L <br />J le <br />?cT , ? rtoo9 <br />pivis?on of t?G12??ion? <br />eJl?n?n? and S5fet`1 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Prowers <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 mal -showing the extent of current disturbances to affeeted --- <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: <br />Permittee Name: <br />Address <br />Phone Number: <br />Fax Number: <br />Mark Dorenkamp <br />Prowers County <br />109 E. Sherman St. <br />Lamar, CO 81052 <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 />Date <br />M: TERMIT\MAS TERDOCUMENTS\M-AF-04