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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: /Elk Creek Sand & Gravel, LLC Rc <br />PERMIT NO.: /M-1978-208 ~~~,~~~~ <br />OPERATION NAME: ShaffersCrossing ~ijUNj <br />_ vDivision j10p7 <br />ANNUAL FEE DUE:TE. $$281 002(D eon or before your anniversary date Mm~ne aRd S e~ °n, <br />COUNTY: Jefferson <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 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 report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee. report, and associated <br />map. If no new disturbances or reclamation have occurred durinc the previous year and no new chances to <br />the previous year's map are necessary. then no new map is required, provided that the Ouerator 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: Juliet A. Moores <br />Permittee Name: Elk Creek Sand & Gravel, LLC <br />Address: P.O. Box 416 <br />Conifer, CO 80433 <br />Phone Number: (303) 816-4047 <br />Fax Number: <br />If ou av dditional comments and/or information that should be provided to the Division, please provide it <br />~ow o jtac it to this form along with your written report and map. Annual Report instructions are enclosed. <br />/j ~ ~ <br />Owner, or Designee <br />Date <br />