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AV QV- ? Pr <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />San Miguel County <br />M-1981-220 <br />Klondike Pit <br />November 20, 2009 <br />OCT 16 200,9 <br />Division ct <br />K,.cl_ma#ion, <br />?'°u1t,?ry and <br />Safety <br />$791.00 (Due on or before your anniversary date) <br />San Miguel <br />- According-to-C.R.& -34--32 5.?=->.> or-G.-?S. 34-32-11-6; each-year; on-the- anni-versar-y-date-of-the-pernvit,-a - <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 vour revised written annual resort 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 may. If no new disturbances or reclamation have occurred during the previous year and no <br />new changes to the previous vear's map are necessarv. 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: Mike Horner <br />Permittee Name: San Miguel County <br />Address: P.O. Box 426 <br />Norwood, CO 81423 <br />Phone Number: (970) 327-4835 <br />Fax Number: (970) 327-4090 <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 />z/lhe-f <br />bate <br />M:\PERMITIMASTERDOCUMENTS\A4-AF-04