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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <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 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: Doug Dean <br />0V 5 - 7 1 eu& a -7 <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />gnature of Co <br />Date <br />#17 Enterprises, LLC <br />P.O. Box 88 <br />0275 CR 22 <br />DeBeque, CO 81630 <br />(970)283 -9420- <br />(970)283 -5227 <br />7/l d2,0I/ <br />to Officer, :, er, or Designee <br />ANNUAL FEE and REPORT REQUEST <br />V #17 Enterprises, LLC <br />M- 1978 -221 <br />K -Bar -T Pit <br />August 23, 2011 <br />$323.00 (Due on or before your anniversary date) <br />Rio Blanco <br />RECEIVEID <br />JUL 2 8 2011 <br />c; Division of reclamation, <br />Miring and Safety <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 />