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ro a c 0,(G <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />r f / Carma Bayshore LLC <br />✓M- 1982 -015 <br />St. Vrain Lakes, Filing 1, Slurry Wall <br />December 10, 2009 <br />$$791.00 (Due on or before your anniversary date) <br />Weld <br />RECWV <br />/DEC 0 9 2009 <br />Divicon or Reclamation, <br />0 Mining 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 accomplis 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; 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 n new changes to <br />t he previous year's map are necessary, then no new map is required, provided that th O shall st ate <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: Tyler- <br />l�►iZ� <br />Permittee Name: / Carma Bayshore LLC <br />Address: ✓188 Inverness Dr. West, Ste. 150 <br />,Englewood, CO 80112 <br />Phone Number: -"(303) 706 -9451 <br />Fax Number: ✓(303) 706 -9453 <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 Corporate Officer, Owner, or Designee <br />/ z / - A ° I <br />Date <br />