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<br />&r <br />ANN AL FEE and REPORT REQUEST <br />PERMITTEE NAME: Jordan C. and Jone L. Burdick <br />PERMIT NO.: /M-1987-092 <br />OPERATION NAME: B & G Stone <br />ANNIVERSARY DATE: August 25, 2009 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Larimer <br />CC'S nr? <br />RftMVE'D <br />I-JU'L 0 8 20" <br />DM940 of 1;jecia mati <br />Mi?9 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 />-reclamation_accomplished_to date_and_during-the_precediag_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 vour 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: Jordan C. Burdick <br />Permittee Name: Jordan C. and Jone L. Burdick 'Qia--1q <br />Address: P.O. Box 1385 4 o-A4,k <br />Lyons, CO 80540 <br />Phone Number: (303) 823-5943 41 ? <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 />G <br />nature of Corporate Officer, Owner, or Designee <br />17- <br />Date