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~~ <br />1 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />~~~ <br />ANNTiAT, FF.F. and RF,PORT RF.QTTFST <br />'~/Four States Aggregates, LLC <br />1/ M-2001-001 <br />Line Camp Pit <br />June l8, 2006 <br />~ECEsa~ED <br />/ ~~~N ~ s zQOs <br />I/ DisisionoJiyt°er°y <br />$658.00 (Due on or before your anniversary date) ~~Bpt°¢r <br />Montezuma <br />V`~ <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 disturbances to affected land,. _ _ _ <br />reclamation accomplished to date aiid during the preceding year, new disturbances that are anticipated to occur I <br />during the upcoming yeaz, 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 ymrr revised written annual rennrt and anm~al repnrf man to this form- Please note [hat 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: Aryol Brumley <br />Permittee Name: Four States Aggregates, LLC <br />Address: P.O. Box 1568 <br />Cortez, CO 81321-1568 <br />Phone Number:. _ (970) 565-3388. , _ _ ~_ <br />Fax Number: (970) 565-1057 <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 />Sign rpora Officer, signee <br />Le ~ ~ Z-o~ <br />Date <br />