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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REOUEST <br />'Colo Water Conservancy Dist. <br />VP /M-1981-086 <br />Borrow Area C <br />July 21, 2011 <br />RECEIVED <br />c/ JUN 13 2011 <br />OlAsion of Reclamation, <br />Uning and Safety <br />$791.00 (Due on or before your anniversary date) <br />Grand <br />-According_.to_C.R.S. 34-32.5-1.1.6 or C.R.-S. 34-3.2-1.16,-_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 may 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 man 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: Jim Struble <br />Permittee Name: N Colo Water Conservancy Dist. <br />Address: 220 Water Avenue <br />Berthoud, CO 80513 <br />Phone Number: (970) 532-7700 <br />Fax Number: (970) 532-0942 <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 />, <br />i re of Co ra fficer, Owner, or Designee <br />Date <br />M:\PERMITkMASTERDOCUMENTS\A4-AF-04