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=~ ~. <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUA~E~ and RE/PORT REQUEST <br />/Adams County RV Park, LLC dba 124th Estates Partners <br />M-2001-085 Rr <br />124th Estates Sand and Gravel Mine C ~~~ ~ "~ <br />Jnly 2s, zoos ~~ _ ~ / I JUG 2 ~ 1007 <br />Di~fon of kec~a~~,o,;~~ . <br />$$~ (Due on or before your anniversary date) Mining and Satery <br />Adams <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 operator <br />shall submit the annual fee, a report and map showing the extent of current distu[bances_to_affecied_land," _ <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual resort and annual report mau to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, reuort, and associated <br />man. If no new disturbances or reclamation have occurred durinc the arevious vear and no new chances to <br />the previous year's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Dave Schultejann <br />Permittee Name: Adams County RV Park, LLC dba 124th Estates Partners <br />Address: 10201 Brighton Rd. <br />Henderson, CO 80640 <br />Phone Number: (303) 287-2721 <br />Fax Number: (303) 287-3153 <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 />tgnature of Corporate Officer, Owner, or De ee <br />e~//~~a~ <br />Date <br />