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ANNUAL FEE and REPORT REQUEST <br />PERMTITEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />A. Blasi & Son Trucking & Earthmoving, Inc. <br />M-2002-109 <br />Cucharas Pit <br />January 24, 2006 <br />$281.00 (Due on or before your anniversary date) <br />Huerfano <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. 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: Anthony Blassi <br />Permittee Name: A. Blassi & Son <br />Trucking & Earthmoving, Inc. <br />Address: 38043 CR 32.4 <br />Trinidad, CO 81082 <br />Phone Number: (719) 845-8785 <br />Fax Number: (719) 845-8786 <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 />Signature of Corporate Officer or Owner <br />Date <br />