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4NF 4' RVT <br />ANNUAL FEE and REPORT RIEOUIEST <br />PERMITTEE NAME: Benson Brothers <br />PERMIT NO:: - - -- M-1-977-062 - J - - - - - -- <br />OPERATION NAME: Hallenbeck Pit No 1 <br />ANNIVERSARY DATE: April 2, 2009 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Delta <br />R <br />F '71) <br />AJAR 2 ? 2009 ? <br />Division of t-waamation, <br />Mining and Safety <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 -wilt be performed-during the coming year; the3ates for tfie beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach vour revised written annual report and annual report may 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 since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Ed Benson <br />Permittee Name: Benson Brothers <br />Address: 21240 Austin Rd <br />Phone Number: <br />Fax Number: <br />Austin, CO 81410 <br />(970) 835-3128 <br />(970) 835-8567 <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 />ignature of Corporate Of icer, Owner, or Designee <br />Date