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AN L FEE and REPORT REQUEST <br />PERMITTEE NAME: ? Crowley County <br />PERMIT NO.: V4-1982-126 <br />OPERATION NAME: Crowley Cnty Grav 2 <br />d? <br />"4PR 0 12010 <br />Dimon of k8cl oa <br />-t,O ""Img and 8nfietl, <br />ANNIVERSARY DATE: April 28, 2010 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Crowley <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 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: Mike Apker <br />Permittee Name: Crowley County <br />Address: 603 Main St. Ste. 2 <br />Ordway, CO 81063 <br />Phone Number: (719) 267-5555 <br />Fax Number: (719) 267-3114 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or ach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />a j414 ati1 ??S <br />ign:?? Corporate Officer, Owner, or Designee <br />-t o 10 <br />Date <br />M: \PERMIT\MASTERDOCUMENTS\M-AF-04