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~v-t3 -off <br />s~ <br />~ ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUN"I'Y: <br />~ /Rio Blanco County <br />l/ M-1995-046 <br />Johnson Draw <br />October 7, 2006 <br />RECEI~,~E® <br />~~''nr.T ' ~~1ng <br />"Division of Reclamaoon, <br />Mining and Safety <br />$688.00 (Due on or before your anniversary date) <br />Rio Blanco <br />__ _ _~#ccording_tn~.R.S^34-32.5= LI6-or .C R.S.~4-32=.1-I6reach-year,_on the anniversary-date of_the-pe-rmit; 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 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 resort and annual resort man to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred during the previous year and no <br />new chances to the previous year's man are necessary, then no new mao is required, provided that the <br />Operator shall state this in the Annual Resort. Please note that an adequately labeled map that clearly <br />delineates and includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Pennittee Contact: <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Ron Leeper <br />Rio Blanco County <br />570 2nd St. <br />Meeker, CO 81641 <br />(970) o° o-~- <br />(970)878-3396 <br />8"qs'-g~59O v <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 Officer, Owner, or Designee <br />Date <br />M: W BRMITIMASTERDOCUMENTSUI-AF-04 <br />