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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />-fip 3- W?-r <br />ANNUAL FEE and REPORT REOUEST <br />Colorado Division of Highways <br />/ M-1979-148 / <br />Myrin Pit <br />February 1, 2011 <br />$323.00 (Due on or before your anniversary date) <br />Routt <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 <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning 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 <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred durine the previous year and no <br />new chances to the previous year's map are necessary, then no new map is required, provided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />delineates and includes the 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: Jason Smith rjP w, - -16 6 lea <br />Permittee Name: <br />Address: <br />Colorado Division of Highways <br />222 S 6th St Rm 317 <br />Grand Junction, CO 81501 <br />Phone Number: (970) 683-6223 <br />Fax Number: (970) 683-6227 <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 <br />enclos <br />O A S T te 04 a le,, o a I <br />Signature f Corporate Officer, Owner, or Designee WAS <br />remove <br />Date <br />4- <br />M: PERMIT\MASTERDOCUMENTS\M-AF-04