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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: V Conejos County <br />PERMIT NO.: / M- 1987 -097 <br />La Florida Gravel Pit <br />August 18, 2011 <br />$323.00 (Due on or before your anniversary date) <br />Conejos <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: Bob Lucero <br />Permittee Name: Conejos County <br />Address: <br />Phone Number: <br />Fax Number: <br />Date <br />M:IPERMITIMASTERDOCUMENTS\M -AF -04 <br />P.O. Box 157 <br />6683 County Rd 13 <br />Conejos, CO 81129 <br />(719) 376 -5772 <br />(719) 376 -5661 <br />44 - PPT <br />RECEIVED <br />AUG 0 <br />Division of ^eu+ nation <br />Mining and Safety <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- reportand - 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 informa ion. Please verify and make any necessary <br />changes: <br />01,--fisA. <br />l��1811 5 / (1 &c�.:e , z . RAJ <br />Q � G i uce29 r4 � <br />C � �C'zlP E� . <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 />5� -s-- <br />Signature of Corporate Officer, Owner, or Designee <br />