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.f Nl ~C___ <br />CI'EE NAME: <br />f NO.: <br />TION NAME: <br />ERSARY DATE: <br />th FEE DUE: <br />ANNT1Ai. FF.F. and RF.PnRT RF.nTTF.ST <br />~ Park County <br />/M-1995-027 <br />Ansley Pit No 2 <br />May 8, 2006 <br />REDE1\(ED <br />~ APR 2 0 2006 <br />i/ Divisioo of Minctato aad Deolopr <br />$281.00 (Due on or before your anniversary date) <br />Park <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 />•h vnnr reviced written annnal report and annnal re nrn t maRtn this form. Please note that an <br />labeled map that clearly delineates and includes the above elements may since for a written <br />records indicate the following permittee contact information. Please verify and make any necessary <br />Permit tee Contact: Dave Kintz p ,Q J ~~ L iN~ ~ <br />Permiti <br />e tee Name: Park County <br />Addr <br />s s: P.O. Box 147 <br /> Faiiplay, CO 80440 <br />Phone Number: (719) 836-4277 ~. ` <br />Fax Nu mber: (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 /> <br />Signatuq~ of Cd fporate fficer, Owner, or Designee <br />l~~g,~v6 <br />Date ~ <br />