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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: <br />Permittee Name: <br />Address: <br />Phone Number: (719) 346 -8139 <br />Fax Number: (719) 346 -7242 <br />If you have additional comm <br />below or attach it to <br />e losed. <br />Sig . line of Corporate Officer, Owner, or Designee <br />- 1g1 t <br />Date <br />Paula Weeks <br />Kit Carson County <br />P.O. Box 160 <br />M:IPE RMITIMAS TERDOCUMENT S\M -AF -04 <br />Burlington, CO 80807 <br />ANNUAL FEE and REPORT REQUEST <br />Kit Carson County <br />M- 1988 -115 <br />Ostrowski Pit <br />December 19, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Kit Carson <br />--ee, sn.VM <br />i ) .0 0 0 2011 <br />u:d._ , : <br />� jpu , y _. Satety <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 />/or information that should be provided to the Division, please provide it <br />with your written report and map. Annual Report instructions are <br />