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.- <br />~~ ~ ~~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Washington County ti~ <br />M-1997-015 <br />Elrick Pit <br />December 19, 2007 <br />$$791.00 (Due on or before your anniversary date) <br />Washington <br />®EC 0 5 -~ <br />2®Q~' <br />Div pin UY ~?ec~a~atfon ~ <br />9 and Sate$y <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 operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />~~ during the upcomirrg-year; reclamation-that "will-be-performed-during-the coming year,-the dates-for-the-beginning - -- <br />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. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the previous year's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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: Jesse Stackhouse <br />Permittee Name: Washington County ~.~~'WI 3/ <br />Address: 501 4th Ave ~~Q' O G - /~~- ~ p ~/ ~-o - boo <br />w~ i~ ewe f~ <br />Otis, CO 80743 - y,~~S d - " "- -A1~ <br />Phone Number: (970) 246-3347 ~J O' <br />Fax Number: / `y2_._p <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 enclosed. <br />ignature of orate Officer, Owner, or Designee <br />/ - :~ O - ~- a a 7 <br />Date <br />