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?T+v <br />ANNUAFEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />M/organ Sand & Gravel Inc <br />?VI-1977-094 <br />Westhoff Pit 4 <br />December 20, 2010 <br />$$791.00 (Due on or before your anniversary date) <br />Morgan <br />a/,-- <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 tleevxtent -of current disturbances to affected land, <br />reclamation acc6ftiplished to dafe aiid-dur ng 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 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: Greg Westhoff <br />Permittee Name: Morgan Sand & Gravel Inc <br />Address: 21215 Hwy No 52 <br />P.O. Box 1443 <br />- - - - - - - --Fort Morgan-, CO^-80701`-- <br />Phone Number: (970) 867-8074 <br />Fax Number: (970) 867-3774 <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 Corporate Officer Owner, or Designee <br />Date