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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Af?: +_ ke-r <br />ANNUAL FEE and REPORT RE UEST <br />Douglas County Sand & Gravel, LLC <br />/M-1983-089 <br />Douglas County Sand & Gravel <br />November 8, 2010 <br />V/ RECFjvpn <br />JAN 0 3 2010 <br />-? Di*ion of riion, <br />M'i+ting and safety <br />$$791.00 (Due on or before your anniversary date) <br />Douglas <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 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 may 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 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: John Miner <br />0 -7 <br />?Z <br />Permittee Name: Douglas County Sand & Gravel, LLC <br />Address: P.O. Box 966 <br />Castle Rock, CO 80104 <br />Phone Number: (303) 681-2696 <br />Fax Number: (303) 681-0320 <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 /> <br />Sy ridture of Corporate Officer, Owner, or Designee <br />Date <br />