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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />According -34 -32- -146,- 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: Mark Dorenkamp <br />Permittee Name: Prowers County <br />Address: 109 E. Sherman St. <br />Phone Number: <br />Fax Number: <br />Date <br />Lamar, CO 81052 <br />(719) 336 -5536 <br />(719) 336 -5536 <br />Signa ure of Corporate Officer <br />M.:IPERMITIMAS TERDOCUMENTSth4 -AF -04 <br />ANNUAL FEE and REPORT REQUEST <br />Prowers County <br />VIVI- 1984 -134 <br />Randy Shaw Pit <br />August 31, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Prowers <br />IREcIv <br />1/ AUG262011 <br />(fin at Declamation, <br />Bing and aafety <br />/Od <br />I <br />//0Z90 <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 />ner, or Designee <br />