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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: Oldcastle SW Group, Inc. dba United Companies of Mesa County <br />PERMIT NO.: M-1995-036 <br />OPERATION NAME: Railhead Gravel Pit <br />ANNIVERSARY DATE: October 19, 2010 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Mesa <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 />recla-- =uul:l+UIll1JI---II - a---°---,-IJIIG-,- U Lu d-- ---- - -lI--1G-l:GU-1- - - - - L --- - - - --- <br />?I.LG U-1-1d uurlll- ?' LIIG I1?' yum, IIGW ulJLulvalllicJ UIUL dFU UIRWIPULGU LO UkXUF <br />I cIiIQ.IIIQ. <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 vear's map 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: Justin Aubert <br />Permittee Name: Oldcastle SW Group, Inc. dba United Companies of Mesa County <br />Address: P.O. Box 3609 <br />Grand Junction, CO 81502 <br />Phone Number: (970) 243-4900 <br />Fax Number: <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 />Date