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X <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNM Rad LPORT REQUEST <br />Z <br />Carson County <br />Ostrowski Pit <br />December 19, 2009 <br />$$323.00 (Due on or before your anniversary date) <br />Kit Carson <br />W <br />A IYE - C 2 4 2009 <br />Div*ion O f Reci <br />14 7inB and g °,. <br />According• -to - C.R.S. 34-32.5-4-16 or C.R.S. 34r3.2--l1-6,-each--year-,- on.- the.- anniversary.date_of_the_p -e=- t, 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 ye and no <br />new changes to the previous year's map are necessary, then no new map is required, p rovided 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: Carol Fritz <br />Permittee Name: Kit Carson County <br />Address: P.O. Box 160 <br />Burlington, CO 80807 <br />Phone Number: (719) 346 -8139 <br />Fax Number: (719) 346 -7242 <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 />( :gno lsed. <br />at of�C�orpor e Officer, Owner, or Designee 9 <br />Date <br />M: TERMITWASTERDOCUMENTSN -AF -04 <br />