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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,L16, 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: <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <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 />Kenneth Morrison <br />Lincoln County <br />P.O. Box 39 <br />Hugo, CO 80821 <br />(719) 743-2337 <br />(719) 743 -2815 <br />ature of Corporate Officer, Owner, or Designee <br />D e „ ( ,- eN-r 1 <br />D <br />M:IPERMIT\MASTERDOCUMENTS\M AF -04 <br />rem - 0 <br />l <br />A FEE and REP RT REQUEST <br />1 LincoIn County <br />A- 2002 -108 <br />Eikermann <br />October 29, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Lincoln <br />RECO\ 03) <br />(3C1' 05 ZU <br />Division pt n � and Safety <br />—Ft) Mining <br />