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<br />1?1'v Sr PT <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT RE QUEST <br /> <br />Forest Lakes Metro Dist jct <br />M-1981-158 <br />Forest Lakes Pit #1 <br />January 26, 2010 <br />mVED <br />JAN 19 2010 <br />Division of Keciamation, <br />Mining and Safety <br />$323.00 (Due on or before your anniversary date) <br />La Plata <br />- ?- <br />-?- - --According-to-C-.I?::S-3-4=3-2:5=1-1-6-or-C.R-S:-34=32-=1-1.6; each-year; =omthe-anniversary-date- f 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 your revised written annual report 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: Dale Kortz <br />Permittee Name: Forest Lakes Metro District <br />Address: P.O. Box 440 <br />Bayfield, CO 81122-0440 <br />Phone Number: (970) 884-2925 <br />Fax Number: (970) 884-0305 <br />If you have additional <br />below or attach it.W <br />Signature o; Corporate <br />vents and/or information that should be provided to the Division, please provide it <br />form along with your written report and map. Annual Report instructions are <br />Owner, or Designee <br />M:IPERMITIMASTERDOCUMENTSM-AF-04