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ANNUAL FEE and REPORT REQUEST <br />PE1tMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Colorado Division of Highways <br />M-1978-102 <br />Shippes Pit <br />Jane 29, 2006 <br />$281.00 (Due on or before your anniversary date) <br />Weld <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each yeaz, 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 yeaz, new disturbances that aze anticipated to <br />occur during the upcoming yeaz, 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 vour revised written annual report and annual report mao to this form. Please note that an <br />adequately labeled map that clearly 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: Eric Prieve <br />Permittee Name: Colorado Division of Highways <br />Address: 4340 E. Louisiana Ave. <br />Denver, CO 80222 <br />Phone Number: (303) 757-9432 <br />Fax Number: <br />If you have addifional 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 />Signature of Corporate Officer or Owner <br />Date <br />