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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />,#F,%( <br />ANNUAL FEE and ORT REQUEST <br />V Arkins Park Stone Corp. <br />/M-1994-080 <br />Berthoud Sunset <br />October 28, 2009 <br />Mal?(-- <br /> <br />$$323.00 (Due on or before your anniversary date) <br />Larimer <br />Dr-_ <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°upco-mingycar,-mclamatio:r-that wil-l-be-performed-during-the-c-eming-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 man 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 nd make any necessary <br />changes: <br />Permittee Contact: Judy Sprague <br />Permittee Name: Arkins Park Stone Corp. <br />Address: 5975 NCR 27 <br />-- Loveland, CO 80538 <br />Phone Number: <br />Fax Number <br />(970) 663-1920 <br />(970) 663-2315 <br />If you have additional comments and/or information that should be provided to the <br />below or attach it to this form along with your written report and map. Annual Report Si1u4 re of rporat Offic 9 Owner, or Designee <br />Lj j <br />l,, 2,()07 <br />Date <br />please provide it <br />are enclosed.