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A <br />Y <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REOUEST <br />Montezuma County <br />M-1978-107 <br />T r Pit <br />,avember„Z 2010 <br />0<:(Due on or before your anniversary date) <br />Montezuma <br />W <br />C+V.aG \l C[) <br />, <br />Of"T 1 Zf 7J <br />+ ion i; ve- ,ieaval on, <br />WM9 and v90?`l`f <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 an&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: Lloyd Everett <br />Permittee Name: Montezuma County <br />Address: 1680 North Dolores Road <br />Cortez, CO 81321 <br />Phone Number: (970) 565-8666 <br />Fax Number: (970) 565-8252 <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 />atu of o orate Officer, Owner, or Designee <br />Date <br />M:\PERMIT\MASTERDOCUMENTS\M-AF-04