2010-02-19_REPORT - M1985140 - Laserfiche WebLink

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Y-if - - << PT ANNUAL FEE and REPORT REOUEST PERMITTEE NAME: ?te of David Goss R CEIVED PERMIT NO.: 85-140 EE 1 ? 2010 OPERATION NAME: Goss Sand & Gravel Division of Reclamation, ANNIVERSARY DATE: January 24, 2010 -? Mining & Safety ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) COUNTY: El Paso 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 shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur of active operations, and the date active operations ceased for-the year, if any. Please attach your revised written annual report and annual report map to this form. The Annual Report & Fee requirement is not met until we have received the following components: fee, report, and associated map. If no new disturbances or reclamation have occurred during the previous year and no new changes to the previous year's map are necessary, then no new map is required, provided that the Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. Division records indicate the following permittee contact information. Please verify and make any necessary changes: Permittee Contact: Dean Goss ----fermi ee ame: safe of David-Ci6ss Address: 24040 Falcon Hwy Calhan, CO 80808-9156 Phone Number: (719) 683-4295 Fax Number: (71.Q) 683-2645 If you have add' ional omments and/or information that should be provided to the Division, please provide it below or attach it tot s form along with your written report and map. Annual Report instructions are enclosed. Signature of Corporate Officer, Owner, or Designee Date