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L ~" ~'--_ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />(~ ANNUAL FEE and REPORT REQUEST <br />efferson Couuty <br />~M-1977-245 <br />Pine Junction Pit <br />January 31, 2007 <br />ol~<< <br />" vivisio~'or''ZQQ~ <br />Mihia9 a~a 3a eation <br />ry <br />$$688.00 (Due on or before your anniversary date) <br />Jefferson <br />- -- According-to-~.R:S-34-3?-5-1-16-or-C-.R-5: 34=32-1-16; each year,-on-the-anniversary date-of-t}:e p~-r..it, ar. -- <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 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 resort mau to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated maa. If no new disturbances or reclamation have occurred durinti the arevious year and no <br />new chanties to the previous year's maa are necessary, then no new mau is required, provided that the <br />Operator shall state this in the Annual Reuort. Please note that an adequately labeled map that clearly <br />delineates and Includes the above elements may suffice for a written report. <br />Division records indicate the following petmittee 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 />Phone Number: (303) 271-5205 <br />Fax Number: (303)271-5222 <br /> <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 OfScer, Owner, or Designee <br />`~2/Zo~~ <br />Date <br /> <br />M:SPERMI'r~IvfASTERDOCUMENTSVv1-AF-04 <br />