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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.__3:32.5._116._or C.R.S. 34- 32- .1.16, each year, on the _anniversar_y_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: (970) 327 -4835 <br />Fax Number: (970) 327 -4090 <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 Corp ate Officer, Owner, or Designee <br />I)4 )11 <br />Date <br />M: \PERMITIMASTERDOCUMENTS\M -AF -04 <br />Mike Horner <br />San Miguel County <br />P.O. Box 426 <br />Norwood, CO 81423 <br />40f+ <br />ANNUAL FEE and REPORT REQUEST <br />San Miguel County <br />M- 1981 -154 <br />Norwood Pit <br />November 20, 2011 <br />$791.00 (Due on or before your anniversary date) <br />San Miguel <br />REC IVEd <br />NOV 0 7 2011 <br />Divl�l ®n of Reclamation;, <br />Mining & Safety <br />