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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 />If you have yo . a tistict <br />Date <br />M :\PERMIT MASTERDOCUMENTS\M -AF -04 <br />ANNUAL FEE and REPORT REQUEST t. Division of Reclamation, <br />Mining & Safety <br />y <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 />Phone Number: (970) 683 -6223 <br />Fax Number: (970) 683 -6227 <br />Jeremy Lucero <br />Colorado Division of Highways <br />222 S 6th St Rm 317 <br />Grand Junction, CO 81501 <br />' s wami the <br />e ' . and 1 " env <br />• and $ ex , ss noted <br />Si tbilttrporate Officer, Owner, or Designee <br />'2—I- - 1Z <br />1 - k 1 <br />Colorado Division of Highways <br />M- 1981 -043 <br />N Of Douglas Pass <br />February 1, 2012 <br />$323.00 (Due on or before your anniversary date) <br />Rio Blanco <br />RECEIVED <br />v FEB i5 2012 <br />or information that should be provided to the Division, please provide it <br />g with your written report and map. Annual Report instructions are <br />0 <br />5� ttyks r,vioo <br />Z cX <br />