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a~ 4 <br /> <br />~CO <br />ANNUAL FEE and REPORT REQUEST <br /> ~'? <br />PERMITTEE NAME: ~~Q f 2 ~ ~~Qft <br />uache Count <br />Sa <br /> y <br />g <br />PERMIT NO.: M-1990-114 <br />OPERATION NAME: Noland Gulch <br />ANNIVERSARY DATE: October 26, 2004 <br />ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br />COi.JN"I'Y: Saguache <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 />i; *±~~~i~**+ation_accomglished toslate_and_dtuine the precedin¢ 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 vour revised written annual report and annual resort map 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: <br />Permittee Contact: John Ungefug <br />Permittee Name: Saguache County <br />Address: Road and Bridge <br />P.O. Box 476 <br />Saguache, CO 81149 <br />Phone Number: (719) 655-2554 <br />Fax Number: (719) 655-2543 <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 />S'gn lure of Corpor to Officer or Owner <br />Date <br />-f 7.-0 <br />