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ANNUAL FEE and REPORT REQUEST PERMITTEE NAME: PERMIT NO.: OPERATION NAME: ANNIVERSARY DATE: ANNUAL FEE DUE: COUNTY: 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 shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, reclamation accomplished to date and during the preceding year, new disturbances that aze anticipated to occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning of active operations, and the date active operations ceased for the year, if any. Please attach your revised written annual report and annual resort man to this form. The Annual Report & Fee requirement is not met until we have received the following components: fee, report, and associated maa. If no new disturbances or reclamation have occurred durinti the nrevious veer and no new chanties to the nrevious year's map are necessary. then no new map is required, arovided that the Operator shall state this in the Anuual Report. Please nose that an adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. Division records indicate the following permittee contact information. Plesse verify and make any necessary changes: Russ Van Egmond M-1991-080 Stones Ranch Grav Pt October 2S, 2006 $$281.00 (Due on or before your anniversary date) Teller Permittee Contact: Russ Van Egmond Permittee Name: Russ Van Egmond Address: 546 Doe Valley Rd. Gulley, CO 80820 Phone Number: (719} 689-0877 Fax Number: If you have additional comments and/or information that should be provided to the Division, please provide it below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. Signature of Corporate Officer or Owner Date