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p. 9 -Ir- e,?-r <br />ANNUAL FEE and REPORT RE VEST <br />PERMITTEE NAME: Robert Daugherty =WC-'D <br />PERMIT NO.: / M-2004-048 <br />?/ SrP 27 20111 <br />OPERATION NAME: Cedar Point Picture Rock Quarry <br />pWjeian ?ANNIVERSARY DATE: October 4, 2010 j Rig, rm-"d <br />ANNUAL FEE DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY: San Miguel <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=precediirg year;-imw `disturbatrce?-that areiitiUcipatdd-Co 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 since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Robert Daugherty <br />Permittee Name: Robert Daugherty <br />Address: P.O. Box 1364 <br />Clifton, CO 81520 <br />Phone Number: (970) 434-8773 <br />Fax Number: (970) 242-8438 <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 />S gnature of Corpor Off r, Owner, or Designee <br />Z.S?X/? <br />Date