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?I° <br />ANXA'L FEE and R1EPORT REQUEST <br /> <br />PERMITTEE NAME: Caldwell Brothers <br />PERMIT NO.: dM-1986-016 <br />OPERATION NAME: Caldwell Brothers 3 <br />ANNIVERSARY DATE: June 1, 2011 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Otero <br />.RECEIVED <br />41AY 3 1 2011 <br />/ Division of Kedamation, <br />°0 Kning and Safety <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 />rec4an:atie:: aeeen plashed-tom Sate and-du-ng the-preceding-year,-new disturbances that arc--antieipated-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: Wayne Caldwell <br />Permittee Name: Caldwell Brothers <br />Address: 25026 Rd 19 <br />Rocky Ford, CO 81067 <br />Phone Number: (719) 254-3210 <br />Fax Number: <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 />lc?"z `r?zSL <br />ignature of Corporate Officer, Owner, or Designee <br />5b'2 / <br />Date <br />