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t <br />/~J~~~ r <br />' <br />~~ <br /> ANNUAL F <br />E n <br />PORT REQUEST <br />PERMITTEE NAME: /Pazk County <br />PERMIT NO.: ilvl-1995-027 <br />OPERATION NAME: Ansley Pit #2 <br />ANNIVERSARY DATE: May 8, 2007 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Park <br /> <br /> <br />~tH°1 ~ ~ 20~~ <br />Divl ion or F<aGmnatlon, <br />fining and Sa4aiy <br />According to C.R.S. 34-32.5-] 16 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 yeaz, new disturbances that are anticipated to <br />occur during [he upcoming year, reclamation that will be performed during the coming yeaz, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual report map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessazy <br />changes: <br />Perminee Contact: David Kintz <br />Permittee Name: Park County <br />Address: P.O. Box 147 <br />Phone Number: <br />Fax Number: <br />Fairplay.CO 80440 <br />(719)836-4280 <br />(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 />enclosed. <br />tgnature of Corporate Officer, O , or Designee <br />y~`~~ 7 <br />Date~~ <br />M 9PERMITMASTERD000MEMSIM-AF-OJ <br />