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4 <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />t <br />(.e <br />r' ? J <br />d REPORT REQUEST <br />ANN & FEE an Y <br />'Bent County <br />"M-1992-413 <br />Verhoeff Pit No 2 <br />December 17, 2010 <br />$$791.00 (Due on or before your anniversary date) <br />Bent <br />t. a s.. t. .? <br />„Z <br />?, v 3 ? .rat r ? :'y! <br />JJa?r <br />7v .' <br />v 1 <br />-According to C.R:S:-34-32.5-116 or-C:R-S. 34-32-11-6, each year, _on the._anniv_ersary _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: Fiank - -BrpaTA __?Io NCSA __tUCV1c,1Z, <br />Permittee Name: Bent County <br />Address: P.O. Box 350 <br />Las Animas, CO 81054-0350 <br />Phone Number: (719) 456-2223 <br />Fax Number: (719) 456-0375 <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 />enclosrA. <br />Signature of Corporate OfWer, Owner, or Designee <br />7 /N1M JQgA 1 (4 A Zn <br />Date <br />M:IPERMIT vIASTERDOCUMENTS\M-AF-04