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ANNUAL FEE and REPORT REQUEST PERMTI'TEE NAME: PERMIT NO.: OPERATION NAME: ANNIVERSARY DATE: ANNUAL FEE DUE: COUNTY: 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 shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, reclamation accomplished to date and during the preceding yeaz, new disturbances that aze anticipated to occur during the upcoming year, reclamation that will be performed during the coming yeaz, the dates for the beginning of active operations, and the date active operations ceased for the yeaz, if any. Please attach vour revised written annual report and annual report man to ibis form. The Annual Report & Fee requirement is not met until we have received the following components: fee. report, and associated maa. If no new disturbances or reclamation have occurred during the previous vear and no new changes to the previous year's map are necessary, then no new map is required, provided that the Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the above elements may since for a written report. Division records indicate the following permittee contact information. Please verfty and- make any necessary changes: Logan County M-1978-146 Stephens Pit October 1, 2007 $$791.00 (Due on or before your anniversary date) Logan Permittee Contact: Dustin J. McComtick Pemvttee Name: Address: Logan County 315 Main St., Ste. 2 Sterling, CO 80751 Phone Number: (303) 522-7879 Fax Number: (970) 522-4018 If you have additional comments and/or information that should be provided to the Division, please provide it below or attach it to this form along with your written report and map. Annual Report instmctions are enclosed. Signature of Corporate Officer or Owner Date