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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: David P. Morlan <br />Permittee Name: Rio Blanco County <br />Address: 570 2nd St. <br />Phone Number: <br />Fax Number: <br />Signs re of Corpo <br />Date <br />Meeker, CO 81641 <br />(970) 878 -9590 <br />(970) 878 -3396 <br />M :\PERMIT\MASTERDOCUMENTS\M -AF -04 <br />ANNUAL FEE and REPORT REQUEST <br />Rio Blanco County <br />-� M- 1980 -112 <br />Richard Bachman Pit <br />July 10, 2011 <br />$791.00 (Due on or before your anniversary date) <br />Rio Blanco <br />RECEIVED <br />1 8 2 0 1 1 <br />Division of Reclamation, <br />Mining & Safety <br />-According_to_C.R.S._34- 32.5- 116_or- C.R.S.- 34- 32- 11 each -year,--oil-the anniversary- date -of the permit; -arj— = <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 />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 />fficer, Owner, or Designee <br />