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AN L FEE and qREORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />?Fr ont County <br />2994-118 <br />Phantom Canyon Pit <br />August 8, 2010 <br />REGENED <br />5 WO <br />4 <br />$$323.00 (Due on or before your anniversary date) <br />Teller <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 />- operafor shall submit the annual fee,-a reportand map showing the extent occurrent 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: --Gary Weifton- Curtis Stone <br />Permittee Name: Fremont County <br />Address: -6 1170 Red Canyon Rd. <br />Canon City, CO 81212 <br />Phone Number: (719)-21t"-7360 719-275-2047 <br />Fax Number: (719) 276-7304 <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 />?l <br />Signature of Corporate Officer, Owner, or Designee <br />"'? `-7 - Ib <br />Date <br />43 -LI31LU LKA0 <br />M: \PERMITWIASTERDOCUMENTS\M-AF-04