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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 />operafor`siialtsubmit- the - annual fee,— a=repo and -map- showing the _extento _c_urrent 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: Harry Covey <br />Permittee Name: <br />Address: <br />Phone Number: - <br />Fax Number: <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 />Signature of Corpo <br />Date <br />MIPERMITIMASTERDOCUMENTS 1M- AF -02. DOC <br />) <br />ANN A FEE and REPORT REQUEST <br />Harry Covey <br />,e a <br />- ee - - sews <br />Officer, Owner, <br />Harry Covey <br />✓ M- 1988 -081 <br />Phil Sheridan Lode <br />August 19, 2011 <br />$$86.00 (Due on or before your anniversary date) <br />Boulder <br />esignee <br />C J c 41 2. 9 <br />ECEIVRV <br />AUG 05 ZUi, <br />Division of rceclarriao�,. <br />yr, <br />).lining and Safety <br />1-larr/ Covey <br />/660 6 t i Dr; ve. <br />o r- <br />R)E , Colvrado <br />205110 <br />Cell ,579 4/53$' (3o3) <br />