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.~ <br />• _ ~.. <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 />Bent County <br />M-1992-113 <br />Verhoeff Pit No 2 <br />December 17, 2002 <br /> <br />RECEIVED <br />DEC 0 3 2002 <br />Oivisien of Minerals and GealoBY <br />$688.00 (Due on or before your anniversary date) <br />Bent <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 submit the annual fee, a report and map showing the extent of current disturbances to affected <br />`----"land,-reclamation accompli"shell-to Hate 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 vour revised written annual report and annual reuort man to this form. Please note that an <br />adequately labeled map that clearly delineates arul 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: Gary Pritchard <br />Permittee Name: <br />Address: <br />Bent County <br />P.O. Box 350 <br />Las Animas, CO 81054-0350 <br />_ - _ Phone Number: _ (719) 456-2223 _ _ _ _ <br />Fax Number: (719) 456-0375 <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 [his form along with your written report and map. Annual Report instructions are <br />enclosed. <br />~. <br />Signatuq of Corporate O icer, Owner, or Designee <br />II-1'7-7,.00~ <br />Date <br />M .~PERMIT\MASTERD000M ENTSN7-AF-04 <br />