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<br />~I ~ s ~\ f 1 <br />PERMTTTEE NAME: <br />PERMIT NO.: <br />OPERA"LION NAME: <br />ANNIVL'RSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />J/& L Ready Mix <br />// M-1995-059 <br />Sunny Dale Farm Pit <br />September 15, 2005 <br />RECEIVED <br />~craf2l~ <br />-~ Division of Minerals and Geology <br />$688.00 (Due on or before your anniversary date) <br />Phillips <br />--- According~to-C.R:S-34=32.5=1-if, ar ~RS-94=32=1-tu eaah~ear, on the~anniversary date~fth~pacmi~peraTr'- ' <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected 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 xnur revised written anmral report and annnal repprf mAR,tn this form. Please note that 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: Laurine Koellner <br />Permittee Name: L & L Ready Mix <br />Address: P.O. Box 218 <br />Haxtun, CO 80731 <br />-"-'"Phone um er: ~70)'J74=b1 r4 - <br />Fax Number: (970) 774-6114 <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 />r <br />Signature of Corporate Officer, Owner, or Designee <br />~U- 7 -C7s <br />Date <br />