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P__ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />r <br />e_ l <br />AN UA FEE and REPORT REQUEST <br />r Phillips County <br />vM-1989-095 <br />Schneller Clay Pit <br />November 27, 2010 <br />$$323.00 (Due on or before your anniversary date) <br />Phillips <br />OCT 14 2010 <br />? Div-Sion of Reclamatlon, <br />According to-C:R:S 34-32:5-11-6 or .C,R.S. 3.4,32-116, each year, on the anniversary date of the permit, an <br />---foperator-shall -submit tlie-annual-fee,-a'report -and map-showing=the`extent'of current disturbances to-affecfed - <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: Randy Schafer <br />Permittee Name: Phillips County <br />Address: 221 S. Interocean Ave. <br />Holyoke, CO 80734 <br />Phone Number: (970) 854-3778 <br />Fax Number: (970) 854-3811 <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 orporate facer, Owner, or Designee <br />? <br />/P I ! `3 /. Q /?% <br />Date <br />M: \PERMITUMASTERDOC UMENTSW-AF-04