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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 <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: Lynne Eschbach <br />Permittee Name: Elbert County <br />Address: P.O. Box 116 <br />Phone Number: <br />Fax Number: <br />Kiowa, CO 80117 <br />(303) 621 -3157 <br />(303) 621 -3159 <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 />U_ , � YNt2 cctick <br />Signal( re of Corporate Officer, Owner, or Designee <br />i A ACC 1 <br />Date <br />M \PERMIT \MASTERDOCUMENTS\M -AF -04 <br />ANN A FEE and T QUEST <br />County <br />M- 1988 -101 <br />b M k <br />Fondis Pit <br />December 15, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Elbert <br />DEC 21 <br />Division of Reclamation, <br />.7_7? Mining & Safety <br />Ox- <br />