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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Weld County / <br />M-1981-286 <br />Thomas Gravel Pit 4 <br />March 1, 2004 <br />~ `~ <br />RECEe' ' -'~ <br />FEB 2 0 2G~~ <br />~iiBianmlAtiioxa~cg ~ .``i; <br />$688.00 (Due on or before your anniversary date) <br />Weld <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 />--1and,-reclamation-accomplished-to-date-and-duringthe-preceding year, new-disturbances-that are.anticipated.to <br />occur during the upcoming year, reclamation that will be performed during the coming yeas, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach ynnr revised written anm~al re~prt and anneal rennrt m:{n to this form- please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Greg Nelson <br />Permittee Name: Weld County <br />Address: P. O. Box 758 <br />Greeley, CO 80632 <br />Phone Number: (970) 356-4000 <br />Fax Number: (970) 304-6497 <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 <br />enclosed. <br />~gnature of orporate Officer, Owner, or Designee <br />Date <br />M:\PERMITMASTERDOCUMEMS\M-AF-04 <br />©f~ <br />