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1# <br />?k'L107k <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />P <br />ANAL FEL and REPOT REQUEST <br />/Washington County <br />?M-1997-015 <br />Elrick Pit <br />December 19, 2008 <br />$$791.00 (Due on or before your anniversary date) <br />Washington <br />1 n/1I <br /> <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 updorning 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 suffice 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 M JJ O 1J <br />Address: 501 4th Ave d N d V - _ O o ?- <br />Otis, CO 80743 C ? 4S C)? P4 W%2 'q ; 6. ` o <br />6ce/J')97oSS?a? <br />Phone Number: (970) 246-3347 nD ?? C l 6+ A4 4^t 1, 0, A-1 <br />Fax Number: -70 <br />- 3 46- r 70 2 /? ,P Q ?; ?? <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 />/? Z? ? z IL jj? ? <br />Si ature of C6Vporate Officer, Owner, or Designee <br />;L o o <br />Date