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PERMITTEE NAME: Y1 ason King <br />PERMIT NO.: M-1981-309 <br />OPERATION NAME: V.F. Smith Pit #5 <br />ANNIVERSARY DATE: August 27, 2011 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Washington <br />_ - According_to GR S. 34 32.5 = 1_16 -er-G R.S._34 -3�-� 1 -6, =each ear —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: f <br />Permittee Contact: Mason King A ) rw (1 ( (tiv`e <br />Permittee Name: Mason King o r; • l v . u-e <br />Address: P.O. Box 68 &2=4.0._ . °t K ZeN( 0 D-c9i0 <br />Fax Number: <br />Date <br />Cope, CO 80812 <br />Phone Number: (970) 357 -4245 <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 foyn along with your written report and map. Annual Report instructions are <br />enclosed. <br />A <br />Signature f Corporate Officer, Owner, or Designee <br />M: \PERMITIMASTERDOCUMENTSVMI -AF -04 <br />ANl'QiYAL FEE‘and Real REQUEST <br />