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700 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />r ? -' <br />r / <br />FEE and REPORT REQ VEST <br />ANAL <br />J <br />P erry Johnston <br />41982-044 <br />Glen Johnston Site 1 <br />RECEIVED <br />APR 2 8 8.01,1 <br />Division of Reclamation, <br />Mining & Safety <br />April 23, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Teller <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 operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming_year, reclamation that will be .performed during the coming. year, the dates for the beginning <br />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 Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous Year's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: Jerry Johnston <br />Permittee Name <br />Address: <br />Jerry Johnston <br />13800 Hwy. 24 <br />Box 99 <br />Divide, CO 80814 <br />Phone Number: (719) 687-9043 <br />Fax Number: <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 enclosed. <br />A J\A I (a PAn n ?f)X] <br />S'g ature Co rate Officer, Owner, or Designee <br />- <br />Date