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<br /> ANNUAL FEE an RE"OUEST <br />PERMITTEE NAME: AAdams County RV Park, LLC dba 124th Estates Partners <br />PERMIT NO.: A4-2001-085 <br />OPERATION NAME: 124th Estates Sand and Gravel Mine <br />ANNIVERSARY DATE: July 25, 2009 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Adams <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, <br />an operator shall submit the annual fee, a report and map showing the extent of current disturbances to <br />affected land, reclamation accomplished to date and during the preceding year, new disturbances that are <br />anticipated to occur during the upcoming year, reclamation that will be performed during the coming <br />year, the dates for the beginning of active operations, and the date active operations ceased for the year, <br />if any. <br />Please attach your revised written annual report and annual report may to this form The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, <br />and associated may. If no new disturbances or reclamation have occurred during the previous <br />year and no new changes to the previous year's map are necessary. then no new man is reauired. <br />provided that the Operator shall state this in the Annual Report. Please note that an adequately <br />labeled map that clearly 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 <br />necessary changes: <br />Permittee Contact: Dave Schultejann <br />/6z <br />Permittee Name: Adams County RV Park, LLC dba 124th Estates Partners RECEIVED <br />JUL 16 2003 <br />Address: Division of Reclamation, <br />P(:5, [o)( / 1 p Mining and Safet., <br />Henderson, CO 80640 <br />Phone Number: (303) 28-7-2:721 <br />7oz®- <br />Fax Number: 287-3 t 53 <br />Y 2 --?} ZY