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ANNUAL FEE and REPORT RE UEST <br />( IV <br />PERMITTEE NAME: Upland Gravel, Inc. <br />PERMIT NO.: / M-2005-077 <br />OPERATION NAME: V Upland Gravel Pit No. 3 <br />ANNIVERSARY DATE: July 5, 2010 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Mesa <br />F610CRA40 <br />JUL U 6 7010 <br />01*ian car ki=-wn Won, <br />1? &VAIR9 and Safety <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: Gary Ri <br />Permittee Name: Upland Gravel, Inc. <br />Address: P.O. Box 1380 <br />1 s--2-- 3X <br />r? <br />Clifte nG_ot-SW C?-ela -7.14 <br />&,J, el 5' ;0 41' <br />Phone Number: (970) 434-0510 <br />Fax Number: (970) 434-6510 <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 />ignature of Corporate Officer, Owner, or Designee <br />12-1- l o <br />Date