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<br /> ANNUAL FEE and REPORT RE VEST <br />PERMITTEE NAME: K Holsinger ,/ <br />PERMIT NO 052 <br />M <br />1980 <br />.: - <br />- <br />OPERATION NAME: Holsinger Gravel Pit <br />ANNIVERSARY DATE: Apri123, 2008 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Jackson <br />1~~® <br />MAR 10 ~ppg / <br />division o. Reciwmation,~ <br />Arlining and Safety b <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 -duriirg-the-grecedingyoar~ crew-disturbances-that ~[re~riic3pa~ed-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 during the previous year and no new changes to <br />the previous year's map are necessary, then no new map is required, provided that the Operator 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 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: Keith Holsinger <br />Permittee Name: K Holsinger <br />Address: P.O. Box 37 <br />Walden, CO 80480 <br />Phone Number: (970) 723-4587 <br />Fax Number: (970) 723-4771 <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 />i ature of orporate Officer, er, or Designee <br />~/ ~~~~ <br />Date <br />yo„~~~.,,za <br />