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t <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />A?- *. QvOr <br />ANNUAL FEE and REPORT REOUEST <br />tl/ <br />? Colorado Division of Highways <br />M-1985-170 <br />BLM Burnt Shale Pit <br />February 1, 2011 <br />$323.00 (Due on or before your anniversary date) <br />Garfield <br /> <br />y <br />- According- to-C.R-.-34-32:5-116 or-C.R.S. 34-32-1-16, 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 during the previous year and no <br />new changes 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 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: Jason Smith a p y L,.. v?? ?l <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Colorado Division of Highways <br />222 S 6th St Rm 317 <br />Grand Junction, CO 81501 <br />(970) 683-6223 <br />(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 />enclosed <br />X?' . Alo lnngt/?r'ul / PC " ovej ;n 2010 <br />Signature Corporate Officer, Owner, or Designee 1_ <br />I-It <br />Date <br />M:IPERMITkMASTERDOCUMENTS\N4-AF-04