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OK- <br />6mk <br /> g r1 0 <br /> I <br />AN UAL FEE and REPORT REQUEST <br /> <br />PERMITTEE NAME: City of Cripple Creek <br />/ <br />PERMIT NO.: V <br />M-1993-039 <br />OPERATION NAME: Midland Gravel Pit <br />ANNIVERSARY DATE: August 4, 2009 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Teller <br />CIRVED <br />JU L 17 2009 <br />Dhftien of Recl,?0260R, <br />40 Mitring and Safety <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 prece mg year, new i s t u ra nces t at are an icipa e o <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 vour 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,: fee, report, and <br />associated associated map. If no new disturbances or reclamation have occurred no new disturbances or reclamation have occurred duringtheprevious year and no and no <br />new chances to the previous vear's map are necessarv, then no new map is required, provided that the <br />Operator shall state this in the Annual Report. state this in the Annual Report. Please note that an adequately labeled map that clearly <br />delineates and includes the 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: Chip Huffman <br />Permittee Name: City of Cripple Creek <br />Address: 337 E. Bennett Ave. <br />P.O. Box 430 <br />Cripple Creek, CO 80813 <br />Phone Number: (719) 689-2125 <br />Fax Number: (719) 689-0121 <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 />6?1 AL111-- <br />Signature Corporate Officer, Owner, or Designee <br />o7-05- 09 <br />Date <br />M:\PERMITIMASTERDOC[IMENTS\ I-AF-04