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<br /> <br />PERMTI'TEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Washington County <br />M-2001-012 <br />Shook Gravel Pit 1 <br />May 31, 2004 <br />$688.00 (Due on or before your anniversary date) <br />Washington <br /> <br />RECE!° ^-a~ <br />APR 9 5 20D4 <br />Division of Miners , .,, _ <br />T 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 disturbancesthaL.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 />]?lease attach your revised written annual refit and annual re nn rt m,~ to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Charles J. Kuntz <br />Permittee Name: Washington County <br />Address: 150 Ash St. <br />Akron, CO 80720 <br />Phone Number: (970) 345-2701 <br />Fax Number: (970) 345-2702 <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 orporate facer, Owner, or Designee <br />Dam <br />M;~PERMITU4ASTERDOCUMENTSNI-AF-04 <br />