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J1616"l- <br />e <br />AL FEE and REPORT REQUEST <br />PERMITTEE NAME: ss Van Egmond <br />PERMIT NO.: ?Z_1991-080 <br />OPERATION NAME: Stones Ranch Grav Pt <br />ANNIVERSARY DATE: October 25, 2010 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Teller <br />RECEIVED <br />/MAR 02 2011 <br />a <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 operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />-- -r-UVW rrcn. .. EMU M-u-N-LE; anu CUT it , 1 Q 1 1 <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour revised written annual report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred during the previous year and no new changes to <br />the urevious vear's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />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 />Phone Number <br />Fax Number: <br />Russ Van Egmond <br />Russ Van Egmond <br />546 Doe Valley Rd. <br />Guffey, CO 80820 <br />(719) 689-0877 ' U:> -? ' <br />n <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 enclosed. <br />gnature of Corporate ice , ty r, or Designee <br />ja'y? ('5 ?C <br />Date <br /> <br />