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~~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUN'T'Y: <br /> <br />Washington County <br />M-1997-015 <br />Elrick Pit <br />December 19, 2004 <br />$688.00 (Due on or before your anniversary date) <br />Washington <br />~N <br />C,'.'[C :~~: <br /> <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 cunent disturbances to affected land, <br />reclamation accomplished to date and during the preceding yeaz, new disturbances that aze anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach ynnr revised written anmial report and annnal re~nr[ main to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: D p ~ a <br />Permittee Contact: Charlie 7. Kuntz ~~_~~VI~A~-t~-C.td: nl bd y~ '~8~4~ <br />Permittee Name: Washington County /~ <br />Address: 5014th Ave ~yCO J~oppCeyr,n ?~ ~K~a.--pt_~ <br />~/,t~pL~~t4,d~ T.Cc%t. ~6~-~.n~/ 1,~ 4~cGpCB;r+C~ <br />Otis, CO 80743 ~(,t_?-r~• 2/,A _/~.,v~.~N,r4 ~,,~P,U~ <br />Phone Number: (970) 246-3347 <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 />Signature of C~rporate Of r, Owner, or Designee <br />- /~"D <br />Date <br />