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<br />ANNiiAi. FF.F, and RFPnRT RR~iiF.ST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Saguache County <br />M-1990-114 <br />Noland Gulch <br />d ICJ <br /> <br />DEC 3 1 2003 <br />October 26, 2003 Division of Minerals and Geology <br />$688.00 (Due on or before your anniversary date) <br />Saguache <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 ymrr revised written annnal rennrt and annnal rennrt m ~n 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: John Ungefug <br />Permittee Name: Saguache County <br />Address: Road and Bridge <br />P.O. Box 476 <br />Saguache, CO 81149 <br />Phone Number: (719) 655-2554 <br />Fax Number: (719) 655-2543 <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 />a re of Corporate Offic Designee <br />~( ~lti~b3 <br />Date <br />MiPERM7TU1A5TERD000MENTSNI-AF-04 <br />