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'L <br /> ~ <br /> ORT REQUEST <br />ANNUAL FEE an <br />PERMITTEE NAME: Pazk County <br /> / <br />PERMITNO.: /M-1995-021 <br />OPERATION NAME: Chaparral Pit <br />ANNIVERSARY DATE: Apri124, 2007 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Pazk <br /> <br />RECEIVED <br />MARL 6 2001 <br />Dlvisn~;t of Reclamation, <br />~hning and Safety <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 yeaz, new disturbances that aze 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 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 necessary <br />changes: <br />Pemtlttee Contact: David Kintz <br />Permittee Name: Pazk County <br />Address: P.O. Box 147 <br />Fairplay.CO 80440 <br />Phone Number: (719) 836-4280 <br />Fax Number: (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 />Signature of Corporate Offic caner, or Designee <br />~i 3 -~ ~ <br />Date <br />+:.xz~ <br />