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17, <br />ANNUAL FEE and REPORT REQUEST J! <br />ry, J ?" Z00 <br />?.ie u <br />PERMITTEE NAME: City of Greeley <br />PERMIT NO.: M-2002-020 <br />OPERATION NAME: 25th Avenue Site <br />ANNIVERSARY DATE: May 30, 2009 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Weld <br />According-to_C.R.S_ 34-32.5-116_or C.R.S._34-3.2-U-6,-each _year,}on.the _anni-v_u-sar-y-_ate £ the permit _ an_ <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning 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 map to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred during the previous year and no <br />new changes to the previous vear's map are necessary, then no new may is required, provided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />delineates and includes the 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: Suzanne Bassinger <br />Perm ittee Name: City of Greeley <br />Address: 1100 10th St., Suite 300 <br />Greeley, CO 80631 <br />Phone Number: (970) 350-9804 <br />Fax Number: (970) 350-9805 <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 <br />enclosed. <br />Signature of Corporate Officer, Owner, or Designee <br />Date <br />M:IPERMrI1MASTERDOCUMENTS\Ivl-AF-04