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f <br />a ORT REQUEST <br />ANJEFEt' <br />PERMITTEE NAME: lz?_,e77-459 County <br />PERMIT NO.: »i <br />visidn vtROo1er00?i9i1, <br />OPERATION NAME: Lake County Grav Pit Mining & safety <br />ANNIVERSARY DATE: July 8, 2010 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Lake <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 vour revised written annual report and annual report man 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 chances to the previous vear'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: Brad Palmer <br />Permittee Name: Lake County <br />Address: P.O. Box 952 <br />Leadville, CO 80461 <br />Phone Number: (719) 486-0259 <br />Fax Number: (719) 486-8479 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or a it to this form along with your tten report and map. Annual Report instructions are <br />e osed. <br />S ature KcNmforate Officer, Owner, or Designee <br />(- to <br />Date <br />M:\PERMITqvLASTERDOCUMENTS\M-AF-04