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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 />r . <br />SignaturOf Corporate <br />//k <br />Date <br />M:IPERMIT\MASTERDOCUMENTS WI -AF -04 <br />Randy Schafer <br />Phillips County <br />221 S. Interocean Ave. <br />Holyoke, CO 80734 <br />(970) 854 -3778 <br />(970) 854 -3811 <br />fficer, Owner, or Designee <br />ANN / E and REPORT REQUEST <br />Pyllips County <br />C&2004-052 <br />Rafert Pit <br />September 20, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Phillips <br />RECEivE <br />AUG 18 <br />2011 <br />Division c;► nc►xnnation, <br />I Mining and Safety <br />n <br />ZZ� <br />According. to C.R.S. 3_4_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 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 />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 />