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d/o <br />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 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 are anticipated to occur <br />during_the upcoming year reclamation that will be performed- during -the coining 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: <br />Elva Mast s <br />C) c <br />Permittee Name: Elva Masters <br />Address: 25901 US Highway 36 <br />P.O. Box 47 <br />Anton, CO 80801 <br />ig <br />Date <br />Phone Number: <br />Fax Number: <br />(970) 383 -2345 <br />(970) 383-2347 <br />attire of Corporate Officer, Owner, or Designee <br />ANN 16POR QUEST <br />L" FEE and <br />l�v Masters <br />UM -2010 -037 <br />Masters Pit #2 <br />October 5, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Washington <br />inECENTO 0 3 2011 <br />Division of Reclamation, <br />AAi ing and Safety <br />11 <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 enclosed. <br />o%- <br />