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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />g: -j- d7 <br />ANNUAL FEE and REPORT REOUEST <br />Costilla County <br />V <br />M- 1980 -233 <br />Costilla <br />December 11, 2009 <br />DEC 18 2009 <br />Divieien of Reclam&#Oa, <br />Kning and Safety <br />$323.00 (Due on or before your anniversary date) <br />Costilla <br />According to C.R.S. 34- 32.5 -1 -16 or C.R.S. 34 -32 -116, each year, on the anniversary 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 vour revised written annual resort 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 vear's map are necessary, then no new map is requi 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 suff ce 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 Valdez <br />Permittee Name: Costilla County <br />Address: P.O. Box 130 <br />San Luis, CO 81152 <br />Phone Number: (719) 672 -9109 <br />Fax Number: <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. C <br />Signature of Corporate Officer, Own or Designee <br />iZ, lts-lor <br />Date <br />MAPERMITI"TERD0CUMENTS\M -AF -04 <br />