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?? <br />ANNUAL FEE and P RTlREQUEST <br />ason King <br />PERMITTEE NAME:7M-2004-036 <br />PERMIT NO.: OPERATION NAME: Kin Pit t lwwnAR" <br />ANNIVERSARY DATE: August 5, 2010 40 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Washington <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 report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamaif&i tl of will be perforinedduring the coming year;-thedates -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 vear's man are necessarv, then no new map is reauired, 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: Mason A. King r <br /> <br />Permittee Name: Mason King --YVeyf- CO-f KO vNeXA-1) <br /> <br />Address: <br />P.O. Box 68 <br />? ?UYbU.Lt?-?S ?Y t <br />V"eciaVv"raV' <br /> ' evt wS <br /> <br />Cope, CO 80812 <br />_ V-t JaS j <br />KO 14 <br /> IK f ?I r <br />Phone Number: (970) 357-4245 <br />Fax Number: (970) 357-4349 <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 long with your written report and map. Annual Report instructions are enclosed. <br />Signature f Corporate Officer, Owner, or Designee <br />4 5-L -10 <br />Date