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PERMITTEE NAME: �( Timothy D. Williams & Betty J. Williams <br />` Ti <br />PERMIT NO.: �M -2010 -054 <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: Timothy D. Williams <br />Date <br />■ <br />•..:orate Officer, Owner, or Designee <br />Signature of C <br />/ <br />M :\PERMIT\MASTERDOCUMENTS\M -AF -04 <br />ANNUAL FEE and RE RT REQUEST <br />Permittee Name: Timothy D. Williams & Betty J. Williams <br />Address: 5588 CR 210 <br />Walsenburg, CO 81089 <br />Phone Number: (719) 738-6263 <br />Fax Number: (000) 000 -0000 <br />Williams Pit No. 1 <br />December 28, 2011 <br />$323.00 (Due on or before your anniversary date) <br />Huerfano <br />A <br />O EC EN .. <br />OV j0 2011 <br />vision of Reclamation, <br />Mining and Safety <br />C Sa <br />/Ca <br />/ / re; <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 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 />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 />