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Av 4- CZilllr <br />ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: Rio Blanco County r ?® <br />PERMIT NO.: M-1995-046 <br />Johnson Draw L_?CCT 15 2009 <br />OPERATION NAME: <br />Division or F?eclarnation, <br />ANNIVERSARY DATE: October 7, 2009 31 mining and Safety <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Rio Blanco <br />---According _to _C-R_S: 34-3?2-.5-116_ or-_C.R_._S.--14-=32 1-1=6; each-year;--on-fhe=anniversery -cTafe o_f:Vf6_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 may 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 chances 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: Ron Leeper <br />Permittee Name: Rio Blanco County <br />Address: 570 2nd St. <br /> Meeker, CO 81641 <br />Phone Number: (970) 878-9590 <br />Fax Number: (970) 878-3396 <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 />q- z3'0? <br />Date <br />M:\PERMITIMASTERDOCUMENTS\M-AF-04