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~~ <br />/ ANNUAL FEE and REPORT REQUEST <br />RECEB\/ED <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />/Conejos County <br />/ M-1987-097 <br />La Florida Gravel Pit <br />~/ JUL 101006 <br />Olvlelon of Minerals and GeoloBY <br />August 18, 2006 <br />$281.00 (Due on or before your anniversary date) <br />Conejos <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 submitthe amual-fee;-a rcport-ard-map showing the extent of current dish:rbances 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 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 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: Bob Lucero <br />Permittee Name: Conejos County <br />Address: 6683 County Rd: 13 <br />P O Box 157 <br />Conejos, CO 81129 <br />Phone Number: {719) 376-5772 <br />Fax Number: {719) 376-5661 <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 />4~ ~ ~~~.~,-7 <br />Signature of Corporate Officer, Owner, or Designee <br />~ =-~-~~ <br />Date <br />M:~PEAMINNASTEAD000MENTSVN-AF-04 <br />