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RECEIVED <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Jefferson County <br />M-1977-245 <br />Pine Junction Pit <br />January 31, 2004 <br />$688.00 (Due on or before your anniversary date) <br />Jefferson <br />JAN 07 2004 <br />givisipn of Minerals & Geology <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-ace©mplished-to-date•and-during-the-preceding-year; new-disturbances-thaE-are-ancieipated-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 rennrt man 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 />Permittee Contact: Paul G. Rice <br />Permittee Name: Jefferson County <br />Address: 21401 Golden Gate Canyon Rd. <br />Golden, CO 80403-8108 <br />Fax Number: (303) 271-5222 <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 o Corporate Officer, Owner, or Designee <br />ifa.nrr~.~ ~ 5. ~o a H <br />Dale <br />M:\PERM ITU1ASTERD000MENTSVN-AF-04 <br />