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I- . r . <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Mr-__ C) t_"_ <br />F;F_CmR5VD <br />AFE3 0 5 2010 <br />j Dlvi ion of Reclamation, <br />T"LS1VI'ning and Safety <br />I <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 upcoming year, reclamation that will be performed during the coming 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 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 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: Chris Zadel <br />Permittee Name <br />Address <br />Northern <br />9075 WCR 10 <br />ANNt 47FEEi' I PORT REQUEST <br />Northern Colorado Constructors, Inc. Aggregate Div <br />M 2001-107 <br />NCCI Pit #1 <br />February 27, 2010 <br />$$791.00 (Due on or before your anniversary date) <br />Weld <br />Colorado Constructors, Inc. Aggregate Div <br />Ft. Lupton, CO 80621 <br />Phone Number: (303) 857-1754 <br />Fax Number: (303) 857-2933 <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 />21 ? I ?.a <br />Date