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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Dolores County <br />M-1995-010 <br />Black Snag <br />March 24, 2011 <br />RECE0 <br />? M 2 5 2011 <br /> <br />$323.00 (Due on or before your anniversary date) <br />Dolores <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 may to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated may. If no new disturbances or reclamation have occurred during the previous year and no <br />new changes to the previous year's may 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: Tim Huskey <br />Permittee Name: <br />Address: <br />Dolores County <br />P.O. Box 608 <br />Dove Creek, CO 81324 <br />Phone Number: (970) 677-2328 <br />Fax Number: (970) 677-3759 <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 />110 - <br />Signature of Corporate Officer, Own , or Designee <br />- V -ll <br />Date <br />M: \PERMIT\MAS TERDOCUMENTS\A4-AF-04 <br />