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<br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: Forest Lakes Metro District JAN <br />?_. 4?011 <br />PERMIT NO.: M-1981-158 ? of? <br />OPERATION NAME: Forest Lakes Pit #1 <br />ANNIVERSARY DATE: January 26, 2011 <br />ANNUAL FEE DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY: La Plata <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 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 may to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated may. If no new disturbances or reclamation have occurred during the previous year and no <br />new chances 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 since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Dale Kortz <br />Permittee Name: Forest Lakes Metro District <br />Address: <br />Phone Number <br />Fax Number: <br />P.O. Box 440 <br />Bayfield, CO 81122-0440 <br />(970) 884-2925 <br />(970) 884-0305 <br />If you have additio <br />below or attach it <br />enclosed. '_ <br />Signature of <br /> <br />comments and/or information that should be provided to the Division, please provide it <br />this form along with your written report and map. Annual Report instructions are <br />, Owner, or Designee <br />rp A-?AcKgf> j}nt&u n(- RE-Re-r <br />M:\PERMIT\MASTERDOCUMENTS\Iv4-AF-04