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ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Farnsworth Construction & Gravel Co. <br />M- 2004 -025 <br />North Fork Pit <br />April 22, 2006 <br />$281.00 (Due on or before your anniversary date) <br />Delta <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 />ch your revised written annual report and annual report may to this form. Please note that an <br />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: Patricia M. Farnsworth <br />Permittee Name: Farnsworth Construction & Gravel Co. <br />Address: 175 Hwy 133 <br />Phone Number: <br />Fax Number: <br />Paonia, CO 81428 <br />(970) 527-0434 <br />(970) 527 -5522 <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 />