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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />1 <br />AN?FEE'and ORT RE QUEST <br />P?ent County <br />/M-2004-057 <br />Reyher Trusts Pit <br />January 27, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Bent <br /> <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the`anniversary--date -of tie permit, ari <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 vour 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 vear's map are necessary, then no new may 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: O N ©? l?l C,Ib L?, <br />Permittee Name: Bent County <br />Address: P.O. Box 350 <br /> 725 Bent Ave <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 />encl d. <br />Signature of Corporate Offic , Owner, or Designee <br />Z-cg?2Z6 <br />Date <br />M:IPERMITIMAS TERDOCUMENTS\M-AF-04 <br />