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c c <br />!/ <br />ANN AL FEE`°and_ ORT REQUEST <br />PERMITTEE NAME: ZDrn Ready Mix Corp. <br />PERMIT NO.: 1974-092 <br />OPERATION NAME: Barlow Pit <br />ANNIVERSARY DATE: October 31, 2009 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Morgan <br />r <br />RFCPIVF-® <br />,e/SEP 2 9 2009 <br />Division o•, leclamation, <br />k4ining 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 preceding year, new disturbances that are anticipated to occur <br />--during-the-upc-oming-year,_:recl_amation 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 />man. 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: Doug Dowling <br />Permittee Name: Dorn Ready Mix Corp. <br />Address: 19671 Rd R 7 <br />P.O. Box 636 <br />Fort Morgan, CO 80701 <br />Phone Number: (970) 867-2968 <br />Fax Number: (970) 867-7443 <br />If you have additional comments and/or information that should be <br />below or attach it to this form along with your written report and map. <br />Sign re of Corporate Of cer, Owner, or Designee <br />provided to the Division, please provide it <br />Annual Report instructions are enclosed. <br />Date