2006-10-11_REPORT - M1998059 - Laserfiche WebLink

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tCJ' 13 ~~ :~ `ANNUAL FEE and REPORT REQUEST ~~~ PERMTTTEE NAME: PERMIT NO.: OPERATION NAME: ANNIVERSARY DATE: ANNUAL FEE DUE: COUNTY: ;, /L & L Ready Mix I/ M-1998-059 Sunny Dale Farm Pit September 15, 2006 ~ nrr ~ 1 7nr~6 ~ ®Itfi§Idfi tlf Reclamation, MIRIR~ end Safety $688.00 (Due on or before your anniversary date) Phillips According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the ammiversary date of the permit, an operator shat subm~*.-the arm ual fee, areport-an3 map-showing the extent Gf ourrent d:siurbanc:.s tG affected lard, reclamation accomplished to date and during the preceding year, new disturbances that are 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 report map to this form. The Annual Report & Fee requirement is not met until we have received the following components: fee, report, and associated map (All are required regardless of the level of disturbance or absence of disturbance during the previous year). Please note that an adequately labeled map that clearly delineates and includes the above elements may since for a written report. Division records indicate the following permittee contact information. Please verify and make any necessary changes: Permittee Contact: Laurine Koellner Permittee Name: Address: Phone Number: Fax Number: L & L Ready Mix P.O. Box 218 Haxtun, CO 80731 (970)774-6114 (970)774-6114 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. Stature of Corporate Officer, Owner, or Designee a9-iy~ Date /o'lo - d