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Air *- A?T <br />ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Wilbur F Benham <br />V/M-1984-039 <br />Toltec No 2 <br />RECF?VE p <br />MAR 2 4 2011 <br />.Division <br />Mlnli $ Sa.? on, <br />April 25, 2011 <br />$259.00 (Due on or before your anniversary date) <br />San Juan <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 />- --- <br />-- -- - -operator-shal"ubmit-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 man If no new disturbances or reclamation have occurred durine 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 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: Wilbur F. Benham <br />Permittee Name: Wilbur F Benham <br />Address: 1012 Kennedy Dr., Apt A <br />Norton, KS 67654 <br />Phone Number: (785) 874-8080 <br />Fax Number: /1/16 "') C <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 />2j_zWv <br />Signature of Corporate Officer, Owner, or Designee <br />Date <br />M:IPERMITIMASTERDOCUMENTS/M-AF-02.DOC