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?tv <br />i <br />?V <br />ANN AL FE9 and WORT REQUEST <br />PERMITTEE NAME: , rr wers County 7SE CEI <br />PERMIT NO.: M-1984-134 P02LU 1 t,I <br />OPERATION NAME: Randy Shaw Pit <br />Division of Reclat"gildHl <br />ANNIVERSARY DATE: August 31, 2010 '/D Mining & saiuty <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Prowers <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 anT 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 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: Mark Dorenkamp <br />Permittee Name: Prowers County <br />Address: 109 E. Sherman St. <br />Lamar, CO 81052 <br />Phone Number: <br />Fax Number: <br />(719) 336-5536 <br />(719) 336-5536 <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 <br />enclosed. <br />Signature of orporate Officer, Own r, or Designee <br />Date <br />M:IPERMIT\MASTERDOCUMENTSVv1-AF-04 <br />