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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />- RRI-- <br />ANNUAL FEE and REPORT RE UEST <br />ACA Products, Inc. <br />M-1979-010 -? <br />Avery Construction Pit <br />January 15, 2009 <br />$791.00 (Due on or before your anniversary date) <br />Chaffee <br />REFC1_=11/e1) <br />JAN o 2ZODS <br />"Wo <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 />- - dur-ing-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 vear's map are necessarv. 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: Jon Hollenbeck <br />Permittee Name: <br />Address: <br />ACA Products, Inc. <br />702 Gregg Drive <br />P.O. Box 1887 <br />Buena Vista, CO 81211 <br />Phone Number: (719) 395-3790 <br />Fax Number: (719) 395-3794 <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 />c <br />Signature of E;iforate Officer, Owner, or Designee <br />I?- L4 <br />Date