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~~~ <br />ANNUAL FEE and REPORT REQUEST <br /> ~ECEia~ED <br />PERMITTEE NAME: t/ Four States Aggregates, LLC <br />~ <br />j <br />PERMIT NO 1990 <br />025 <br />M ' <br />UN ~ 5 TOQg <br />.: - <br />~ <br />- ~ <br />OPERATION NAME: Hay Camp Pit r~s'0" °t Mtnarats andGea°gr <br />ANNNERSARY DATE: May 22, 2006 <br />ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br />COUNTY: Montezuma <br />~L <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 araldnrittgthe preceding year, new di`s ances haT are a`nhcipated Yo ' <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 mac 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 />Permiitee 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 />Si e~ <br />- t Z - o [P <br />Date <br />