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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 />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished fo 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. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written <br />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 />Date <br />M: \PERMIT \M ASTERDOC U MENTS\M -AF -04 <br />D ell Kko <br />Fremont County <br />P-A -DuA 39 <br />Phone Number: (x#1'7 <br />Fax Number: (48- <br />Signature of Corporate Officer or Owne <br />vit-yo <br />ANNUAL FEE and REPORT REQUEST <br />Fremont County <br />M- 1994 -092 <br />Iron Mountain Road Gravel Pit <br />January 23, 2002 <br />$281.00 (Due on or before your anniversary date) <br />Fremont <br />RECEIVE <br />JAN 14 2002 <br />Division of Minerals and Geology <br />\)“7 ` 3 �u1'r . <br />Co-w c 1 , C C? <br />1 <br />Cre ,P. 4 � �\ Cf T. <br />615 NI yk 'r- -,v <br />- 275 7b?4' <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 />