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N <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />3 Rf )r <br />AL FEE and REPORT REOUEST <br />Z ashington County <br />-1998-065 <br />Hayes Pit <br />September 18, 2010 <br />(Y906- OK <br />RECEIVE' <br />SEP Q 8 Z01Q <br />lafiiirta.Sy <br />$$323.00 (Due on or before your anniversary date) <br />Washington <br />According to C.R.S. 34732.5-116 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: Jesse J. Stackhouse <br />Permittee Name: Washington County <br />Address: <br />Phone Number: <br />Fax Number <br />150 Ash Avenue <br />Akron, CO 80720 <br />/ 4co to cw .4 d S- <br />fgo,5 <br />Z?? J1097-11-7- <br />- 6'_;-6-.9. 0/& <br />(970) 345-2701 qO <br />S 9 CC Gc„R C c{ <br />(970) 345-2702 '¢ <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 />enclose <br />Si ature of rporate Officer, Owner, or Designee <br />- V6- o?o1d <br />Date <br />M: \PERMITUvIAS TERDOC Un4F-NT SUFI-AF-04 <br />:;5