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ANN AL FEE And REPORT REQUEST <br /> <br />PERMITTEE NAME: R Elbert County <br />/ <br />PERMIT NO.: IA <br />1-2001-010 <br />OPERATION NAME: Allison Gravel Pit <br />ANNIVERSARY DATE: August 14, 2009 <br /> <br />"CSIVEID <br />/AUG d 4 2009 <br />Div*Wn of Reclan`?atio?s, <br />Mipting and Safety <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Elbert <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 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 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: y 1A1J("j <br />Permittee Name: <br />Address <br />Elbert County <br />P10- 800 1110 <br />c'"'if 69-4069-5- k?n Uja . co ?(31/ Il <br />Phone Number: (719?- „ ? 303-0-J%-3J5 <br />Fax Number: Q 1 Q? ca I gad '303 - 1 _ <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 />enclose . <br />Signat e of Corporate Officer, Owner, or Designee <br />Date <br />M:IPERMITIMASTERDOC U M ENTS\M-AF-04