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<br />PERMITTEE NAME: Adams County RV Park, LLC dba 124th Estates Pas <br />PERMIT NO.: M-2001-085 C~~ (/cD <br />C <br />OPERATION NAME: 124th Estates Sand and Gravel Mine '~(~( ? 3 ? <br />ANNPJERSARY DATE: July 25, 2003 D,V t sign ~t~~a <br />~'? <br /> <br />ANNUAL FEE DUE: erats <br />tQ <br />$688.00 (Due on or before your anniversary date) a4dCep <br /> ~y <br />COUNTY: Adams <br />According to C.R.S. 34-32.5-I 16 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 hat are anticipated to accur <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 vrmir revised written annnal refit and annnal re nrt m P to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffrce for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Dave Schultejann <br />Permittee Name: Adams County RV Park, <br />LLC dba 124th Estates Partners <br />Address: 4545 E. 60th Ave. -L~i-~r S ce : 1 ~ <br />Commerce Ciry, CO 80022 <br />Phone Number: (303) 287-2721 <br />Fax Number: (303) 287-3153 <br />~ ?~ <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 />//'"_ (~ <br />- Signature of C rporate Officer, Owner, or Designee <br />Date ~ r~ ~ ~ ~ / ~ ~ <br />M:\PERMITU1 ASTERDOCUM ENTSU7-Ar-01 <br />