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dk? <br />AN UAL FEE and PORT REQUEST <br />PERMITTEE NAME: El Creek Sand & Gravel, LLC <br />PERMIT NO.: M-1978-208 <br />OPERATION NAME: Shaffers Crossing RECEIVED <br />ANNIVERSARY DATE: June 16, 2010 '11SEP 2 9 2010 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary dat7?0 slc?n of Floclama?opCOUNTY: Jefferson Mining & sj,,0tj <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 fhe 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: Juliet A. Moores <br />Permittee Name: Elk Creek Sand & Gravel, LLC <br />Address: P.O. Box 416 <br />Conifer, CO 80433 <br />Phone Number: (303) 816-4047 <br />Fax Number: <br />If you have tonal comments and/or information that should be provided to the Division, please provide it <br />below ot,,,+tCa4h ipto this form along with your written report and map. Annual Report instructions are enclosed. <br />SignaV'Te of Corara'Officer, Owner, or Desi net <br />(b <br />Date