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<br />ANP&FEE an ORT REQUEST t'sEVWD <br />PERMITTEE NAME: North Weld Gravel EP 16 2009 <br />Qiviaian of reclamation, <br />PERMIT NO.: -1976-018 -rMiming and Safety <br />OPERATION NAME: North Weld Gravel <br />ANNIVERSARY DATE: October 17, 2009 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: 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 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 preceding 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 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 conta mformatign. Please veri and make any necessary <br />changes: n f `0/ ?l S 'L ?v e u ?r D n G? e ? <br />/'h-?/? ?OoK S ?• ?e?Ld py?? ?9wCx,"l1?ei^ !?? ?P-. <br />Permittee Contact: Leroy A. Bellmore <br />Permittee Name: North Weld Gravel <br />Address: 13480 WCR 100 <br />Nunn, CO 80648-9700 <br />Phone Number: (970) 897-2252 <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 />-9 C., 41 l k-- ? <br />Signature of orporate Officer, Owner, or Des e <br />9 <br />Date