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� • III IIIIIIIIIIIIIIII <br /> 999 <br /> ANNUAL FEE and REPORT REQUEST <br /> ECG„VIED <br /> PERMITTEE NAME: Weld County F <br /> Eti1o100� <br /> PER-MIT OPERA T ON NAME: Pierce Pit <br /> t21 �/llsion al yinera/sandBga <br /> ANNIVERSARY DATE: March 1,2001 <br /> ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br /> COUNTY: Weld <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 <br /> report. <br /> Division records indicate the following permittee contact information. Please verify and make any necessary <br /> changes: <br /> Permittee Contact: Greg Nelson Ok <br /> Permittee Name: Weld County / <br /> Address: P.O. Box 758 <br /> IIIIH. St <br /> Greeley, CO 80632 <br /> Phone Number: (970) 356-4000 <br /> Fax Number: (970) 304-6497 <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 <br /> enclosed. <br /> Signatu of Corporate Officer or Owner <br /> Date <br /> M TERMITWASTERDOCUMENTSW-AF-04 <br />