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1 <br />wee, hhp <br />~iE~E1~~® <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Four States Aggregates, LLC <br />M-2001-001 <br />Line Camp Pit <br />June 18, 2005 <br />$688.00 (Due on or before your anniversary date) <br />Montezuma <br />JUN 1 7 2005 <br />Division of Minerals and Geology <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_o~currentdisturbances_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 anmral red nrt and anmial report man to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Aryol Brumley <br />Permittee Name: Four States Aggregates, LLC <br />Address: P.O. Box 1568 <br />Cortez, CO 81321-1568 <br />Phone Number: (970) 565-3388 <br />Fax Number: (970) 565-1057 <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 />u <br />Signature o rporate cer r or Designee <br />06/15/2006 <br />Date <br />