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4 � ` r <br />AN AL F EE and REPORT REQUEST <br />PERMITTEE NAME: � r f� Wallace F. Burtis <br />PERMIT NO.: " M- 2001 -070 <br />OPERATION NAME: Florence Pit <br />ANNIVERSARY DATE: August 23, 2011 <br />ANNUAL FEE DUE: $$259.00 (Due on or before your anniversary date) <br />COUNTY: Teller <br />AUG 122011 <br />twsiono� s,bc ;a►natian� <br />l ining and SatetY <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 to date and during t e prece s mg year, new . is ur s ances tna are a s a <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 cea -d 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 />5 - <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Wallace F. Burtis <br />Permittee Name: Wallace F. Burtis <br />Address: 66 Dartmouth Ave. <br />Phone Number: <br />Fax Number: <br />Pueblo, CO 81005 <br />(719) 566 -1669 <br />Signature of Corporate Officer, Owner, or Designee <br />Date <br />g- / <br />M:I PERMIT IMASTERDOCUMENTS /M- AF -02 DOC <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 />