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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 -116, each year on the anniversary date of the permit, an operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, reclamation <br />accomplished to date and during the preceding year, new disturbances that are anticipated to occur during the <br />upcoming year, reclamation that will be performed during the coming year, the dates for the beginning of active <br />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 Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous year's map are necessary then no new map is required provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: Paul Morgan <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 enclosed. <br />Date <br />(719) 742 -3155 <br />(719) 742 -3155 <br />nature of Co orate Officer Owner <br />� .ol/ <br />AN AL FEE and REP REQUEST <br />Paul Morgan Excavating, Inc. <br />- 2006 -077 <br />Morgan Pit <br />January 31, 2012 I? U <br />iil $ *9f.00 (Due on or before your anniversary date) <br />Huerfano <br />Paul Morgan Excavating, Inc. <br />581 County Road 420 <br />P.O. Box 82 <br />La Veta, CO 81055 <br />AgeSIVED <br />irn 122011 <br />j_pivision of Reclamation, <br />�U Mining & Safety <br />j c <br />