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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 Report & Fee requirement is <br />not met until we have received the following components: fee, reports and associated map. If no new disturbances or <br />reclamation have occurred during the previous year and no new changes to the previous year's map are necessary, then no <br />new map is required, provided that the operator shall state this in the annual report. Please note that an adequately labeled <br />map that clearly 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: David Kintz <br />Permittee Name: Park County <br />Address: P.O. Box 147 <br />Phone Number: <br />Fax Number <br />Date <br />Fairplay.CO 80440 <br />(719) 836 -4280 <br />(719) 836-4275 <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 />Signature of Corporate Officer, Owner, or Designee <br />M \PERMIT\MASTERDOCUMENTS \M -AF -04 <br />ANNUAL FEE and REPORT REQUEST <br />Park County <br />M- 1980 -014 <br />Eleven Mile Pit <br />April 1, 2012 <br />$791.00 (Due on or before your anniversary date) <br />Park <br />