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<br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNI FEk an PORT REQUEST <br />Wphillips County <br />4-2004-052 <br />Rafert Pit <br />September 20, 2008 <br />OOIC- <br />f - <br />[rocF??I <br />AUG 14 2008 <br />®ivisicit O:' ,,addisiation, <br />Mining and Safety <br />$323.00 (Due on or before your anniversary date) <br />Phillips <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, reclamation <br />accomplished to date and during the preceding year, new disturbances that are anticipated to occur during the <br />upcoming year, reclamation that will be performed during the coming year, the dates for the beginning of active <br />operations, and the date active operations ceased for the year, if any. <br />Please attach vour revised written annual report and annual report may to this form The Annual Report & <br />Fee requirement is not met until we have received the following components: fee, report, and associated may. <br />If no new disturbances or reclamation have occurred durine the previous year and no new chances to the <br />previous year's map are necessary, then no new may is required, provided that the Operator shall state this in <br />the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the above <br />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 />221 S. Interocean Ave. <br />- - "Holyoke, CO 80734 _ _ ? _ _ _ _ -- - -- . _-- - -- ?._-- <br />Phone Number: (970) 854-3778 <br />Fax Number: (970) 854-3811 <br />If you have additional comments and/or information that should be provided to the Division, please provide it below <br />or attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />Address <br />6 n? ?-44 / <br />Signatur f Corporate fficer, Owner, or Designee <br />Date <br />M:IPERMHT\MASTERDOCUMENTS\M-AF-04