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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />A AL FEE and REPORT REQUEST <br />?Elbert County <br />VM-1983-130 <br />West Pit <br />L-U \ I <br /> <br /> <br />September 22, 2009 <br />$$323.00 (Due on or before your anniversary date) <br />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 s all submit the-annual ee; a report an map s owing fl-ie exten?o Curren i`siirbances to`afec`ted" "- <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: <br />Permittee Name: <br />Address <br />1,,4eri4yi+-9pFEw.h <br />Elbert County <br />C' 1 !"? ono c <br />Phone Number: <br />Fax Number: <br /> <br />Lq,-me &cAeAc <br /> <br />I?zo?.?A C? 8o 11'? <br />3o3 -(0'q I-315`7 <br />303--6'?I -31.'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 />4reenclos <br />of Corporate Officer, Owner, or Designee <br />?F2Ti=rn?,?2 i? ado?l <br />Date ' <br />M: TERMITIMAS TERDOCUMENTS\M-AF-04