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<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 />X <br />Moffat County Road Dept. <br />M-2006-076 <br />State Pit No. 38 <br />January 31, 2010 <br />$791.00 (Due on or before your anniversary date) <br />Moffat <br />RECEIVED <br />,/ JAN 2 ? ZOW <br />7 )Iv Division of Reclamation, <br />Mining & Safety <br />-- - -According-to-C--.R:S: 34=32:5=1-16 or C:R:S:-34=32=1-Y6, each-year; on the annivdrsary-date o-fthe permit,-an <br />- "?- <br />operator shall submit the annual fee, a report and map showing the extent 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 changes 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: <br />Permittee Contact: Billy E. Mack <br />Permittee Name: Moffat County Road Dept. <br />Address: P O Box 667 <br />Craig, CO 81626 <br />Phone Number: (970) 824-3211 <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 />vo, <br />Signature q orporate Officer, Owner, or Designee <br />142.7110 <br />Date ' <br />RECEIVED 52C ^V7 2909 <br />M:\PERMIT\MASTERDOCUMENTS\M-AF-04