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11?? <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />,AF <br />ANNUAL EE and REPORT REOUEST <br />k..G. Everist, Incorporated <br />61(-1999-120 <br />Ft. Lupton Sand and Gravel Mine <br />June 1, 2010 <br />e Gs a I<- <br />`-' i <br />,. <br />JUN N 19 <br />Division of Reclamation, <br />Mining & Safety <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 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 c6min;; year, thedates 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 tc) 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: Lvan M. Shults <br />A <br />Permittee Name: L.G. verist, Incorporated <br />Address: 7321 E. 88th Ave., Ste 200 <br />Henderson, CO 80640 <br />Phone Number: (303) 286-2247 <br />Fax Number: (303) 289-1348 <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 />?l <br />Signature o orporate Of icer, (Yvner?or esig e <br />ao? -- U/0 <br />Date