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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />t • • - -' 2 5 - 11 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. 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 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: <br />Permittee Name: <br />Address: <br />Brad Palmer <br />Lake County <br />P.O. Box 952 <br />M:IPERMITIMASTERDOCUMENTS\M -AF -04 <br />Leadville, CO 80461 <br />Phone Number: (719) 486 -0259 <br />Fax Number: (719) 486 -8479 <br />far A- <br />ANNUAL FEE and REPORT REQUEST <br />Lake County <br />M- 1977 -459 <br />Lake County Gray Pit <br />July 8, 2011 <br />$791.00 (Due on or before your anniversary date) <br />Lake <br />If you have additional comments and/or info oirtliat should be provided to the Division, please provide it <br />below or at ash it to this form along nth your written report and map. Annual Report instructions are <br />etlosed. <br />ture bf Corporate Officer, Owner, or Designee <br />RECEIVED <br />V'JUL C F Lot( <br />4 Division of Reclamation, <br />Mining & Safety <br />