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- i <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />?r s E <br />RT REQU <br />ANNUAL FEL and qREO ST <br />2eld County <br />-1980-149 <br />Hokestra <br />March 1, 2010 <br />®iv/S jOh <br />4 V M"'?"9 -3ar? ae/01?, <br />$$791.00 (Due on or before your anniversary date) <br />Weld <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 <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: Greg Nelson <br />Permittee Name: Weld County <br />Address: 1111 H St. <br />P.O. Box 758 <br />Greeley, CO 80632 <br />Phone Number: (970) 356-4000 <br />Fax Number: (970) 304-6497 <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 />SignaKie of CC(Porate Officer, Owner, or Designee <br />Date <br />M: TERMIT\MASTERDOCUMENTSVv1-AF-04 <br />k