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~F ~ R ~ <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 />Kit Carson County -~ K, ~~ ~tyq ~'±~°,~ <br />M-1988-115 / N0~ ~~ 92®~~ _ ~ <br />Ostrowsla Pit 0i~ision of <br />December 19, 2007 MmIn9 and sa egg on. <br />$$323.00 (Due on or before your anniversary date) <br />Kit Carson <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 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 your revised written annual report and annual report man to this form The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred durin the previous year and no <br />new changes to the previous year's map are necessary, then no new map 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 since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: ~~et~yefl'^ <br />Permittee Name: Kit Carson County <br />Address: P.O. Box l60 <br />Burlington, CO 80807 <br />Phone Number: (719) 346-8139 <br />Fax Number: (719) 346-7242 <br />~~ ~irz <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 />e osed. ~.--- <br />Signature of Corporate Of ,Owner, or Designee <br />Date <br />M:~PERMI7IMASTERDOCUMENTSVv1-AE-04 <br />