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999 <br /> ANNUAL FEE and REPORT REOUEST <br /> PERMITTEE NAME: Park County RECEIVEb, <br /> PERMIT NO.: M-1"5-021 APR 12 2011 <br /> OPERATION NAME: Chaparral Pit W11*0 of W"Irsh aria Geaioga <br /> ANNIVERSARY DATE: April 24,2001 <br /> ANNUAL FEE: $281.00 (Due on or before anniversary date) <br /> COUNTY: Park <br /> According to C.R.S. 34-32.5 or C.R.S. 34-32-116, each year. On the anniversary date of <br /> the permit,an operator shall submit the annual fee,a report and map showing the extent <br /> of current disturbances to affected land,reclamation accomplished to date and during the <br /> preceding year, new disturbances that are anticipated to occur during the upcoming year, <br /> the dates for the beginning of active operations, and the date active operations ceased for <br /> the year, if any. <br /> Please attach your revised written annual report and annual report map to this <br /> form.Please note that an adequately labeled map that clearly delineates and includes <br /> the above elements may suffice for a written report. <br /> Division records indicate the following permittee contact information. Please verify and <br /> make any necessary changes: <br /> Pemittee Contact: -J)DUC-1 i(C—t-r[4 <br /> Pennittee Name: :� CDUAl <br /> Address: P. D. 60K. 14'7 <br /> FM r2PLOrU,Cj So440 <br /> Phone Number: - -4'z 70 <br /> Fax Number: <br /> If you have additional comments and/or information that should be provided to the <br /> Division,please provide it below or attach it to this form along with your written report <br /> and map. Annual Report instructions are enclosed. <br /> Signs C cer or Own <br /> A J <br /> Date <br />