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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <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 <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 />Phone Number: <br />Fax Number: <br />Kris Pennington <br />Logan County <br />315 Main St., Ste. 2 <br />Sterling, CO 80751 <br />(970) 522 -7879 <br />(970) 522 -4018 <br />S gnature ofCate Officer, Owner, or Designee <br />I / A4,) 2-6 17 <br />Date • <br />M:IPERMITIMAS TERDOCUMENTS\M -AF -04 <br />AN A FEE a nd REPORT REQUEST <br />o an County <br />g <br />M- 1987 -159 <br />Guenzi S & G Pit <br />December 28, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Logan <br />NOV 222 <br />e lvton of R <br />a s a f ety °A <br />If you have additional comments and /or information that should be provided to the Division, please provide it <br />below or a, ch it this form along with your written report and map. Annual Report instructions are <br />enclo d/ <br />