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0 ' <br />ANNUAL FEE an P(RT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />1 TIudick Excavating, Inc. <br />/M-1985-129 <br />Elbert County Pit <br />November 25, 2009 <br />4_0 .. <br />$$791.00 (Due on or before your anniversary date) <br />Elbert <br />According toC.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an <br />operator shall submit the annual fee, a report andmap showing the exte'nf 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 chances to the previous Year's map are necessary, then no new map is required, provided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />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 necessary <br />changes: N Q CH I M 6IF-5 <br />Permittee Contact: Bill Hudick <br />Permittee Name: Hudick Excavating, Inc. <br />Address: 160 County Rd 118 <br />Franktown, CO 80116 <br />Phone Number: (303) 204-1431 <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 <br />enclosed. <br />Signature o orporate Officer, Owner, or Designee <br />16 It [D9 <br />Date <br />M: \PERMITIMAS TERDOCUMENTS\M-AF-04