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• <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />/ L e* <br />Signature of Corporate Officer, Owner, or Designee <br />M: \PE RMTTIMA S TERDOC UMENTS \M -AF -04 <br />Jesse J. Stackhouse <br />Washington County <br />150 Ash Avenue <br />Akron, CO 80720 <br />(970) 345 -2701 <br />(970) 345 -2702 <br />AN AL FEE and REPORT REQUEST <br />Washington County <br />..41998 -065 <br />7 <br />Hayes Pit <br />September 18, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Washington <br />RECEIVED <br />'iUU 1 <br />of lemarrtahen, <br />40 Mining & Safety <br />According to C.R.S. 34- 32.5- 1-16_or C.R.S. 34 -32 -116, each year - on -the anniversary-date-of the 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: <br />�AS60 L ©co tkA2u <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 />enc ..ed. <br />AO <br />