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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <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 map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: David Kintz <br />Permittee Name: Park County <br />Address: P.O. Box 147 <br />Fairplay.00 80440 <br />Phone Number: (719) 836 -4280 <br />Fax Number (719) 836 -4275 <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 />e e„:4.. ySignature of CorporateeOfficer, r, or Designee <br />Date <br />6/a / <br />M : \PERMIT\MASTERDOCUMENTS\M -AF -04 <br />ANNUAL FEE and REPORT REQUEST <br />Park County <br />-- 1997 -035 <br />Chaparral Pit 2 <br />June 21, 2011 <br />$323.00 (Due on or before your anniversary date) <br />Park <br />R ECEIVED <br />JUN <br />v tbrviolon of Reclamation, <br />Mining & Safety <br />