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~~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />/llKit Carson County <br />rm-1982-094 <br />Kit Carson County <br />June 24, 2007 <br />~/I/IN4 <br />~~~ <br />~~~d . <br />w~.,e:.. <br />~~ ,i <br />Oivis' C 1`2001 <br />~o'a9a~y Sa Qation <br />ty <br />$$281.00 (Due on or before your anniversary date) <br />Kit Carson <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, areport-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 vour 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 vear and no <br />new chanties to the previous year's man are necessary, then no new man 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 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: r>-ytrRrpvsn€~etfl"' <br />Permittee Name: Kit Carson County <br />Address: P.O. Box 160 <br /> <br />~~i2.o C /4 . ryz ( ~ <br />Burlington, CO 80807 <br />Phone Number: (719) 346-8139 <br />Fax Number: (719) 346-7242 <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 fficer, er, or Designee <br />~~ ~ ~ ?mil/~-- <br />M:~PERMITMASTERDOCUMENTShf-AF-04 <br />