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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REOUEST <br />David A. Lincoln <br />M-2001-038 <br />Bennett Sand & Gravel Pit #2 <br />August 6, 2009 <br />$$791.00 (Due on or before your anniversary date) <br />Adams <br />A Z' 0/1-/-- <br />RWMVED <br />JUL 0 8 2009 <br />E)hOliw of Heciamation, <br />Miufig and Safety <br />According-to_C.R-S 34-'t2 5_1 l6-or_C.R.S.3A32-116,-each yearron-the_anniversar_y_ rator <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-willbe performed-during the coming year, the dates for the begi'nnin-g`"-- - <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: David A. Lincoln <br />Permittee Name: <br />Address <br />David A. Lincoln <br />50500 E. 72nd Ave. <br />Bennett, CO 80102 <br />Phone Number: (303) 644-3030 <br />Fax Number: (303) 644-4743 <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 fo along with your written report and map. Annual Report instructions are enclosed. <br />Signature of Corporate Officer, Owner, or Designee <br />7 A /0 9 <br />Date