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Ma, C <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />AL FEE.and REPORT REQUEST <br />North Weld Gravel <br />?? ?M-1976-018 <br />/ RECEIVE <br />EP 10 M0 <br />0/L <br />OPERATION NAME: North Weld Gravel Divisscq pf IRegl m40? <br />41 in' $t '§!fs / <br />ANNIVERSARY DATE: October 17, 2010 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: 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 />reclaation acwmp]ishesl_to date__ancLduring_the_preceding_ year., new disturbances-that-ar"nticipated-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 year's map are necessary, then no new may 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 suff ce for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: h?Pif? / g -?' -fY- S . <br />Permittee Contact: Leroy A. Bellmore <br />Permittee Name: <br />Address: <br />North Weld Gravel <br />13480 WCR 100 <br />Nunn, CO 80648-9700 <br />Phone Number: (970) 897-2252 <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 <br />