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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Milt- <br />AL FEE an PORT REQUEST <br />1 Dilleys Sand & Gravel <br />1 t4I-1981-004 <br />Ayers Pit <br />February 2, 2010 <br />$$323.00 (Due on or before your anniversary date) <br />Morgan <br /> <br />1tv <br />JeD <br />'CoN <br />9 ZM <br />pN??pon or t eclamation, <br />?in?n5 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 upwraing-year; reclamation- that-will-be-performed-during the com-ing-year,, the-dates--for-the-beg-innir_g =- <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 may 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 contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Vernon Dilley <br />Permittee Name: Dilleys Sand & Gravel <br />Address: 1914 Edmunds St. <br />P.O. Box 125 <br />-- Brush, CO 80723 <br />Phone Number: (970) 842-2810 <br />Fax Number: (970) 842-2284 <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 />n'z <br />Signature of Corporate Offic , Owner, or Designee <br />Date a'`?