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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />4) r- + R?-r <br />ANNUAL FEE and REPORT REOUEST <br />Oldcastle SW Group, Inc dba Four Corners Materials <br />/ M-1987-038 <br />Bayfield Pit No. 1 <br />November 15, 2010 <br />,/ (I'C1115 2011. <br />$791.00 (Due on or before your anniversary date` Dlvlsj?oo of La Plata /VY+ <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 />- - mclan:ati r aeccernplisl d tew elate °and=-dur-ing the -precedinb yea avwy ist r i iPa ed a 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 urevious 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: nil -,t" V. <br />Permittee Name: <br />Address: <br />Oldcastle SW Group, Inc dba Four Corners Materials <br />P.O. Box 1969 <br />Bayfield, CO 81122 <br />Phone Number: (970) 247-2172 <br />Fax Number: Q ?) 70) 259 - 363 I <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or aAAch it to this form along with your written report and map. Annual Report instructions are enclosed. <br />of Corporate Officer, Owner, or Designee <br />II/ 12/ -2,01(-) <br />Date