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<br />FiECE1VED <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE; <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Sedgwick County <br />M-1J96-073 <br />Dolezal Gravel Pit <br />November 8, 2002 <br />OCT 2 2 2002 <br />Division of Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Sedgwick <br />According to C.R.S. 34-32.5-ll 6 or C.R.S. 34-32-ll 6, each year, on the anniversary date of the permit, an <br />opera[cr shall submit the annual fee, a reQort and map showing the exta.m of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipa[ed to <br />occur during Che 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 report map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes tlae above elements may since fnr a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Randy Renquist <br />Permittee Name: Sedgwick County <br />Address: <br />_ Phone Number: <br />Fax Number: <br />223 S. Cedar <br />Julesburg, CO 80737 <br />{970) a7a_3576 <br />(970) 474-3558 <br />If you have additional comments andlor 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 orporate O@ficer, Owner, or Designee <br />_0`3-a2 <br />Date <br />M:IPERM IT[NI ASTER DOCU MENTSVVI-AE-OJ <br />