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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: Manuel Torrez <br />Address: 750 Bent Ave. <br />Phone Number: <br />Fax Number: <br />- -Las Animas, CO 81054 <br />o. <br />Signature of Corporate Offi <br />Date <br />(719) 456 -0720 <br />(719) 456 -1609 <br />Owner, or Designee <br />ANN A FEE and RE <br />REQUEST <br />The Fort Lyon Canal Company <br />' A- 2001 -097 <br />Fort Lyon - State Pit No. 1 <br />October 8, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Bent <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 />reclamation accomplished to date and during the preceding year, new disturbances __that_are_anticipated_to_occur <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 your 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 previous year'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 Name: The Fort Lyon Canal Company -sit vat) Onn H qt S _ v£P : Is ti <br />OW Ern la Al tLs I s oly u <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 />RECE ` F. <br />sEt5 7 7011 <br />Boon of Flela n <br />1r aig and <br />