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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: Sam Keeling <br />Permittee Name: Sam Keeling <br />Address: 516 E Virginia <br />PO Box 361 <br />LaVeta, CO 81055 <br />Phone Number: (719) 742 -5557 <br />Fax Number: <br />,‘-e7/ <br />Signature of Corporate Officer er, or Designee <br />Date <br />ANNALFEE'and deORT REQUEST <br />` Sam Keeling <br />(/M- 1991 -081 <br />Keeling Pit <br />September 23, 2011 <br />$323.00 (Due on or before your anniversary date) <br />Huerfano <br />// OCT 04 ZUi <br />Division of rceclamation, <br />-IV Mining and Safety <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 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 />has Q AJO C Lc( r s r �e- I A) S e ,•t <br />Division records indicate the following permittee 'contact information. Please verify and make any necessary <br />changes: <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 />