2010-10-01_REPORT - M2005071 - Laserfiche WebLink

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ANNUAL FEE and REPORT REOUEST PERMITTEE NAME: PERMIT NO.: OPERATION NAME: ANNIVERSARY DATE: ANNUAL FEE DUE: COUNTY: 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 shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, reclamation accomplished to date and miring the preceding year, new ulls urbances that are anticipated to occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning of active operations, and the date active operations ceased for the year, if any. Please attach your revised written annual report and annual report map to this form. The Annual Report & Fee requirement is not met until we have received the following components: fee, report, and associated map. If no new disturbances or reclamation have occurred during the previous vear and no new changes to the previous vear's map are necessarv, then no new map is required, provided that the Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the above elements may since for a written report. Division records indicate the following permittee contact information. Please verify and make any necessary changes: Benson Brothers M-2005-071 Benson Brothers Red Shale Pit November 13, 2010 $791.00 (Due on or before your anniversary date) Delta Permittee Contact: Ed Benson Permittee Name: Benson Brothers Address Phone Number: Fax Number: If you have additional comments and/or information that should be provided to the Division, please provide it below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. Signature of Corporate Officer, Owner, or Designee 21240 Austin Rd Austin, CO 81410 (970) 835-3128 Date