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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNPJERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />City of Cripple Creek <br />M-1993-039 <br />Midland Gravel Pit <br />August 4, 2002 <br />RECEIVED <br />JUL 1 9 2002 <br />Division of Minerals and Geology <br />$281.00 (Due on or before your anniversary date) <br />Teller <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 disturbanc_es_tQ affected _ <br />land, reclamation accomplished to date and during the preceding yeaz, 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. 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. Chip Huffman <br />Permittee Name: City of Cripple Creek <br />Address: 207 County Rd. 89 <br />P.O. Box 430 <br />Cripple Creek, CO 80813 <br />Phone Number: (719) 689-2125 <br />Fax Number: (719) 689-0121 <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 Corporate Officer or Owner <br />Date <br />M:NERMTnMASTERD000MENTSNI-AF-04 <br />