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FROM :Jackson County Road & Bridge FAX NO. :9707234481 Sep.09 2009 11:07AM P2 <br />ANNUAL FEE and REPORT REOVEST <br />/ CRVIE® <br />PERMITTEE NAME: Jackson County V SEP 09 2009 <br />PERMIT NO.: M-1978-266 <br />J7 DivWan of Neclamation, <br />OPERATION NAME: Riley Gravel Pit <br />Mining and Safety <br />ANNIVERSARY DATE: h August 15, 2009 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Jackson <br />According to C.R.S. 34-32.5-116 or C.R.S. 3432-116, 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, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated 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 your revised written annual report and annual report map 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 year's map are necessary, then no new man is required, provided that the <br />Operator shall state this in the Annual Re ort. Please note that an adequately labeled map that clearly <br />delineates and includes the above elements may sufJScefnr a written report. <br />Division records indicate the following permittee contact information. Please verify and. make any necessary <br />changes: <br />Permittee Contact: <br />Permittee Narne: <br />Address: <br />Phone Number: <br />Fax Number: <br />?nrl?/ S <br />Jackson County <br />P.O. Box 488 <br />188 Grant Street <br />Walden, CO 80480 <br />(970) 723-4481 <br />(970) 723-8437 <br /> <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 rporate Officer or Owner <br />Date