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ANNUAL FEE and REPORT REQUEST <br />PERM[TTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Sedgwick County <br />M-1997-061 <br />I{innie Gravel Pit <br />September 5, 2007 <br />S~ ~ - ~-_, <br />- 2007 <br />Olvision o, "ac'amatien <br />•7n~ng and Safety <br />$$323.00 (Due on or before your anniversary date) <br />Sedgwick <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 />opera[or shall submit the annual fee, a report and map showing-the extent of currcnrdisturbances to affected <br />land,- reclamation accomplished fo 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 your revised written annual report and annual report map to this form. 'fhe Annual <br />Report & Fee requirement is not met until we have received the following components: fee, reuort, and <br />associated map. If no new disturbances or reclamation have occurred durine the previous vear and no <br />new chances to the previous year's map are necessary, then no new man is required, provided that the <br />Operator shall state this in the Annual Report. 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 permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Randy Renquist <br />Permittee Name: Sedgwick County <br />Address: 223 S. Cedar <br />Julesburg, CO 80737 <br />Phone Number: (970) 474-3576 <br />Fax Number: (970) 474-3558 <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 C rporate Offi r, Owner, or Designee <br />9- ~ o ~ <br />Date <br />M:~PERM ITN1ASTERD000M ENTS~M-AF-04 <br />