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l sk C9*-- <br />1 2 <br />AL FEE Zd PORT REQUEST <br />PERMITTEE NAME: R7G ou x Gravel <br />PERMIT NO.: (A. 2000-059 <br />OPERATION NAME: Geroux Gravel <br />ANNIVERSARY DATE: February 22, 2010 <br />ANNUAL FEE DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY: Custer <br />?eCe'VZD f69 7 J, zo'a <br />r ®lv16/Of ? <br />R ? l?? tlan, <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-anticipate-&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 vour 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 vear's man are necessarv. 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: Darrell Geroux <br />Permittee Name: Geroux Gravel <br />Address: 1100 CR 160 <br />- - - ?_ - -WesMcliffe? COQ - <br />Phone Number: (719) 783-2709 <br />Fax Number: (719) 783-2709 <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, Ownef, or Designee <br />Date