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<br />r <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br /> <br />ANNUAL FEE an REPORT UEST <br />Colorado Dept. of Transportation <br />/M-1978-102 <br />MWENM <br />,IN 2 2-1009 <br />©h*W" of F aep; <br />?i Alft and 8lt#@ ij <br />Shippes Pit <br />June 29, 2009 <br />$$323.00 (Due on or before your anniversary date) <br />Weld <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 <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />-` - land, redlamatlo`n accompZished'to"-date and-during the prece id ng year, new disturbances ilia`t are anficipat`ed 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 man 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 necessarv, then no new map is reauired, 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: Gary DeWitt <br />Permittee Name: Colorado Dept. of Transportation <br />Address: 3971 W Service Rd <br />Evans, CO 80620 <br />Phone Number: (970) 506-0359 <br />Fax Number: <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below r attach it to this form along with your written report and map. Annual Report instructions are <br />encl <br />Signature of orporate Officer, Owner, or Designee <br />D <br />M:IPERMITIMAS TERDOCLMENTS\iM-AF-04