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s"'" <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE and REPORT REOUEST <br />_kA Five Rivers Ranch Cattle Feeding LLC <br />I-1977-223 <br />Wiley Pit <br />February 7, 2009 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Prowers <br />jIe <br />0"t-- <br />N 2,9 ?D <br />Divisior? of ®®9 <br />MInin9 and a?iOn <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 during the previous year and no new changes to <br />the previous vear's man are necessarv, then no new man 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: Mike Jacobson <br />Permittee Name: Five Rivers Ranch Cattle Feeding LLC <br />Address: 2258 US Hwy 50 <br />Phone Number: <br />Fax Number: <br />Lamar, CO 81052 <br />(719) 829-4841 <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 />Signature o orporate Officer, Owner, or Designee <br />Date