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'fir Rl� <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: Y Rio Grande County <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />_ According to C.R.S. 34- 32.5_L16_or_C.R.S.. 34-32- 1_16,_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 />Permittee Contact: <br />Permittee Name: <br />Address: <br />Patrick Sullivan <br />Rio Grande County <br />168 N. Washington <br />/ M- 1978 -066 <br />10 Miles South Pit <br />October 22, 2011 <br />$791.00 (Due on or before your anniversary date) <br />Rio Grande <br />Monte Vista, CO 81144 <br />Phone Number: (719) 852 -4781 <br />Fax Number: (719) 852 -0305 <br />✓ OCT 2 `i 2U'i 1 <br />0, Division 01 Keclamation, <br />Mining and Safety <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or - • . - it to this form along with your written report and map. Annual Report instructions are <br />encl <br />ignature of Corporate Officer, Owner, or Designee <br />/ - 7 % // <br />Date <br />M: \PERMITIMASTERDOCUMENTS\M -AF -04 <br />