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ANNUAL FEE and REPORT RE UEST <br />PERMITTEE NAME: Yalsenburg Sand & Gravel Co., Inc. RECEIVED <br />PERMIT NO.: Y M-1978-283 <br />APR 13 ZU11 <br />OPERATION NAME: Sand Arroyo Division of ReciamaVon, <br />ANNIVERSARY DATE: April 24, 2011 Mining & Safety <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Huerfano <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 antic?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 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 vear's map are necessarv, then no new map is reauired. 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: Louis Vezzani <br />Permittee Name: Walsenburg Sand & Gravel Co., Inc. <br />Address: P.O. Drawer 352 <br />Walsenburg, CO 81089 <br />Phone Number: (719) 738-1883 <br />Fax Number: (719) 738-1883 <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 />Si ature of orporate Officer, er, or Designee <br /> <br />Date