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~~ ~ ~~ <br />ANNUAL FEE and REPtORT REQUEST <br />PERMITTEE NAME: Philli s County ~/~ <br />P / <br />PERMIT NO.: M-2004-023 <br />OPERATION NAME: Haynes Hereford Ranch Pit <br />ANNNERSARY DATE: June 2, 2008 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Phillips <br />~~~~~~~® <br />~aY ~~ 6 zoos / <br />Division of Reclamation,'~U <br />Mining and Safety <br />__ ____._According_to C.R.S. 34-32.5-1.16 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 map 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 during 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: Randy Schafer <br />Permittee Name: Phillips County <br />Address: 221 S. Interocean Ave. <br />_ Holyoke CO 80734 _ <br />Phone Number: <br />Fax Number: <br />(970) 854-3778 <br />(970) 854-3811 <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 />Signatur f Corpora Officer, Owner, or Designee <br />~-~%2 ~Q 8 <br />Date <br />M:IPERMIT1MASTERDOCUMENTSUv1-AF-04 <br />