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.- PERMITTEE NAME: <br />PERMIT NO.: <br />Permittee Contact: <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: 75y, 'o <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 <br />"-' operator shall submit "tfie 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 />Mark Dorenkamp <br />Prowers County <br />109 E. Sherman St. <br />Lamar, CO 81052 <br />(719) 336 -5536 <br />(719) 336 -9633 <br />ielAr <br />'JAL FEE and REPORT REQUEST <br />rowers'County <br />JM- 2002 -062 <br />Davis Pit <br />October 16, 2011 <br />$'x:00 (Due on or before your anniversary date) <br />Prowers <br />RECEIVED <br />/OCT 14 2011 <br />DWIsIon of flsolamollon, <br />Mining & Oaf* <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 />Signature of Corporate Officer, 0 'er, or Designee <br />Date <br />M APERMITNASTERDOCUMENT S\M -AF -04 <br />oa -A/3 -4.47soe <br />