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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_._3_4- 32- L16,_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: Allen W. Watts <br />Permittee Name: Kiowa County <br />Address: P.O. Box 100 <br />Phone Number: <br />Fax Number: <br />Eads, CO 81036 <br />(719) 438 -5810 <br />(719) 438 -5327 <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 />Date <br />Signature of Corporate Officer, Owner, or Designee <br />7 -11 <br />M. I PERMI T I MASTERDOC UMENTS 1M -AF -04 <br />AN AL FE and PORT REQUEST <br />(69owa County <br />vM -1983 -112 <br />Murdock Gravel Pit <br />August 25, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Kiowa <br />RECERfFp <br />/AUG 01 2011 <br />Tv <br />