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1 1 <br /> <br />NO'1 i ~:' ZC04 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />San Miguel County <br />M-1981-220 <br />Klondike Pit <br />November 20, 2004 <br /> <br />91ui5ioo of Ittineralx & Gcolody <br />$688.00 (Due on or before your anniversary date) <br />San Miguel <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_submitahe annual fee, a report and map showing th_e 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 anneal re~yGrt and annual report mad 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: Mike Homer <br />Permittee Name: San Miguel County <br />Address: P.O. Box 426 <br />Norwood, CO 81423 <br />Phone Number: (970) 327-4835 <br />Fax Number: (970) 327-4090 <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 />i~~~ /~~ <br />Signature of Corporate Officer, Owner, or Designee <br />Date ~~~ <br />M:~PEAMITN1A57-ERDOCUMEMSNI-AF-04 <br />