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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: Jack Allen <br />Permittee Name: Allen Drilling and Excavating <br />Address: P.O. Box 398 <br />651 Hwy 285 <br />— - - - Fairplay, CO- 80440- — - - <br />Phone Number: <br />Fax Number: <br />(719) 836 -2672 <br />(719) 836 -0715 <br />Signat , re of orp • ate Officer, Owner, or Designee <br />- r <br />ANN AL FEE and RE ORT REQUEST <br />V .IrAll Drilling and Excavating <br />- 2005 -080 <br />Allen Pit <br />October 24, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Park <br />! F'p 1 f 7 <br />�a of <br />qc, Mining anti safe y <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 />`durin 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 />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 />