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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />IQ�J,Q 7 <br />FE and REPORT RE QUEST <br />AN AL E Q <br />ert County <br />- <br />M -1988 10 1 <br />Fondis Pit <br />December 15, 2009 <br />i <br />$$791.00 (Due on or before your anniversary date) <br />COUNTY: Elbert <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 <br />operator shall submit the annual fee, a report and map showing the ektent 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 ma to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components fee, report, and no <br />associated map If no new di sturbances or reclamation have occurred during t he previous year and he <br />new changes to the previous ear's may are necessa then no new ma is required, rovided that the <br />Operator shall state this in the Annual Repo 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: <br />Permittee Name <br />Address: <br />Phone Number: <br />Fax Number: <br />Marilyn -SpFee� <br />Elbert County <br />P D 6"t 11 <br />ICS -iujA Go 20117 <br />, ;503 -�a1 -31'5`1 <br />- 303 6;a l - 3159 <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 />4 Signa of Corporate Officer, Owner, or Designee <br />0 I o9 <br />Date <br />M: \PERMIT \MASTERDOCUMENTS\M -AF -04 <br />