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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />AF ' % <br />ANNUAL FEE and REPORT REQUEST <br />Mike Bennett <br />jI-2007-021 <br />Bennett Pit <br />June 18, 2009 <br />$$323.00 (Due on or before your anniversary date) <br />Yuma <br />0i(f <br />e(z s <br />r <br />VAY 2 6 2609 <br />Division of Recam&600, <br />7LV M MIg 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 />-- - -reelamati©n-accompl.ished_to_date_and_during_ the_pr_eceding_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 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 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 Bennett <br />Permittee Name: Mike Bennett <br />Address: 39533 Co. Rd. 18 <br />Holyoke, CO 80734 <br />Phone Number: (970) 854-2381 <br />Fax Number: <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 of Corporate Officer, Owner, or Designee <br />5'-Z /-a9 <br />Date