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<br />ANNUAL FEE and REPORT REOUEST RD <br />PERMITTEE NAME: George F. Gallegos '?AUG 0 5 2010 <br />PERMIT NO.: ? M-1983-164 t? ©iviaia?n or i ccamzWon, <br />1?Ainir?g and Safety <br />OPERATION NAME: Gallegos Pit <br />ANNIVERSARY DATE: August 25, 2010 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Conejos <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 operator <br />shall- .submit-_the-annual-fee, -a--r-eport-and-map-shoving-the-e-xtent-of current -disturbances -ta--affected-land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />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 Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous year's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: Gale Swafford <br />Permittee Name: George F. Gallegos _ <br />Address: 11.0. Box 520 "l • D x c5pS <br />Romeo, CO 81148 <br />Phone Number: <br />Fax Number: <br />(719) 843-0715 <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 enclosed. <br />ignature of orporate Officer, wner, or Designee <br />Date