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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: <br />Fax Number: <br />(719) 456 -2223 <br />(719) 456 -0375 <br />Si na ure of Corporate Offi r; Owner, or Designee <br />/a- - o)f)/,) <br />Date <br />M:U'ERMIT WMASTERDOC U MENTS\M -AF -04 <br />REPORT VEST <br />ANNU L E and Q <br />Ronda Bucholz <br />Bent County <br />P.O. Box 350 <br />725 Bent Ave <br />Las-Animas,-CO. -84054 -0350 <br />Bent County <br />M- 2004 -057 <br />Reyher Trusts Pit <br />January 27, 2012 <br />$$791.00 (Due on or before your anniversary date) <br />Bent <br />RECEIVED <br />/DEC14201 <br />Division of Reclamation, <br />re Mining & Safety <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 />end. <br />