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•_ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />According to C RS73 2:5=1- 1-6= er -GR: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 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: ik <br />a LA �Perm e Contact: Darryl Schulz rer•% <br />Permittee Name: Otero County <br />Address: P.O. Box 511 <br />13 W. 3rd St. <br />La Junta, CO 81050 <br />Phone Number: (719) 383 -3035 <br />Fax Number: (719) 383 -3935 <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 />enclos <br />Suture of Corporate Officer, Owner, or Designee <br />Date <br />M.:1PERMIT MASTERDOCUMENTS1M -AF -04 <br />ANNUAL FEE`and PORT REQUEST <br />xi) <br />a 'Otero County <br />✓M- 2004 -027 ° {e` °am ation , <br />Mendenhall Pit p °�+ °sW ng 86 $elet <br />August 20, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Otero <br />/MUGaA"" <br />