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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br /> <br /> <br /> <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 />-rdclamatiion -at Lomplished to-date-and-during- the-preeeding-year; new-disturbances that are antie pated-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 may 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 vear's map 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: Chris Zadel <br />Permittee Name <br />Address <br />Northern <br />9075 WCR 10 <br />(fl aC__ otA_ <br />A 1!5 /i°r <br />AN AL FEE and REPORT REQUEST <br />rthern Colorado Constructors, Inc. Aggregate Div <br />M-2001-107 <br />NCCI Pit #1 <br />February 27, 2011 4v <br />$$791.00 (Due on or before your anniversary date) <br />Weld <br />Colorado Constructors, Inc. Aggregate Div <br />Ft. Lupton, CO 80621 <br />Phone Number: (303) 857-1754 <br />Fax Number: (303) 857-2933 <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 />Signature of Corporate O ficer, Owner, or Designee <br />Date