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PERMITTEE NAME: ason King <br />PERMIT NO.: M- 2004 -036 <br />OPERATION NAME: King Pit <br />ANNIVERSARY DATE: August 5, 2011 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Washington <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 operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />_ __reclamation_accomplished to date and during the preceding year new.. disturbances_ that_ar -e_anticipated_to._occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />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 Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous year's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: Mason A. King <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Mason King <br />P.O. Box 68 <br />Cope G0= 80812 <br />(970) 357 -4245 <br />(970) 357 -4349 <br />f � <br />ANL, FEg and UORT REQUEST <br />� 1,4 <br />S <br />Jo i w N4-141 f d v <br />e c (`re Ir i�- b <br />r4,-,4a_ 1k 2 all m 7 W <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 arm along with your written report and map. Annual Report instructions are enclosed. <br />Si gnat !re of Corporate Officer, Owner, or Designee <br />2. c'G1 <br />Date <br />