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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: <br />Permittee Name: <br />Address: <br />Phone Number: (970) 677 -2328 <br />Fax Number: (970) 677 -3759 <br />ignature of Corporate Officer, <br />7 / /...2//l <br />Date <br />M:\PERM T\MASTERDOCUMENTS\M -AF -04 <br />ANNUAL FEE and REPORT REQUEST <br />1 Dolores County Road & Bridge Dept. <br />M- 2008 -020 <br />Pribble Pit <br />August 4, 2011 <br />$323.00 (Due on or before your anniversary date) <br />Dolores <br />RECEIVE <br />,11II 21 2011 <br />V Division of Reclamation, <br />Mining & Safety <br />According -to C.R.S. -34- 32.5 -1 - 16 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 />Tim Huskey <br />Dolores County Road & Bridge Dept. <br />1010 N. Guyrene <br />PO Box 608 <br />Dove Creek, CO 81324 <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 />er, or Designee <br />