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��I <br />J � <br />/' <br />AF l <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: "Prowers County l <br />PERMIT NO.: k'1- 1977 -387 <br />OPERATION NAME: Bates Pit <br />ANNIVERSARY DATE: December 1, 2009 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Prowers <br />According to C.R.S_ 34_2_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 distur- bances- 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 repor 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: Mark Dorenkemp <br />Permittee Name: <br />Address <br />Prowers County <br />109 E. Sherman St. <br />Lamar, CO 81052 <br />Phone Number: (719) 336 -5536 <br />Fax Number: (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, OvKer, or Designee <br />'�//` <br />Date <br />M: �PERMITUMASTERDOC UMENTSW -AF -04 <br />