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f I 1 I <br />A AL FEE and REPORT REQUEST <br />County <br />s <br />PERMITTEE NAME: "Philli p ty <br />PERMIT NO.: ✓M -1990 -116 <br />OPERATION NAME: Kennedy Pit <br />ANNIVERSARY DATE: October 26, 2011 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Phillips <br />Mf <br />� Ol r 1 5 2011 <br />�� 9a Roc/ ���oq <br />� aati <br />-- According- to-C. -R -S- 34=32.- 5- 1- 16 =or- G.R.- S.- 34 -32- -1-16, -each year,_on_the_anniversary date of th 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 />Permittee Contact: Randy Schafer <br />Permittee Name: Phillips County <br />Address: 221 S. Interocean Ave. <br />Holyoke, CO 80734 <br />Phone Number: (970) 854 -3778 <br />Fax Number: (970) 854 -3811 <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 />evn <br />Signatur orporate fficer, Owner, or Designee <br />9/x/0( <br />Date <br />M:\PERMITWIASTERDOCUMENTSWI-AF-04 <br />