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�� -A- C�4� <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPOU REQUEST <br />Rivera's Excavation <br />M- 2004 -053 <br />Riveras Excavation Gravel Pit <br />December 29, 2009 <br />$323.00 (Due on or before your anniversary date) <br />Costilla <br />DEC 6 k! � q c <br />Y <br />✓®EC 18 2009 <br />Div Mi Mining and 8dfetY R, <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 operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected lan ^_ <br />- reclamation accoriplished- to- date-arrd during the - prezle tng - year ,new dis�nces that are anficipatec7fo occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour revised written annu report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components fee, report, and associated <br />map If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous vear's map are necessary, the no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: Eleuto J. Rivera <br />Permittee Name: Rivera's Excavation <br />Address: P.O. Box 24 <br />Amalia, NM 87512 <br />Phone Number: (505) 586 -1059 <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 enclosed. <br />c <br />Signa re of Co rate Officer, Owner, or Designee <br />Date <br />