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ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: Farnsworth Construction & Gravel Co. ?A pfj) <br />LJ; <br />PERMIT NO.: M-2004-025 <br />OPERATION NAME: North Fork Pit Cam' = - <br />ANNIVERSARY DATE: April 22, 2009 <br />ANNUAL FEE DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY: Delta <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 />'re`cI-ama ion accomp is e o ate an urmg- a preceding year, new ?isfi?rrbances ata-? ntkVat c <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 man to this form The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />man. 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 may 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: Patricia M. Farnsworth <br />Permittee Name: Farnsworth Construction & Gravel Co. <br />Address: 175 Hwy 133 <br />Paonia, CO 81428 <br />Phone Number <br />Fax Number: <br />(970) 527-4434 <br />(970) 527-5522 <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 />,s <br />Signature of Corpora e Officer, Owner, or Designee <br />A/ -i 7-0 <br />Date