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PF 4k— <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: Elk Creek Sand & Gravel, LLC <br />PERMIT NO.: /M -1978 -208 <br />OPERATION NAME: Shaffers Crossing <br />ANNIVERSARY DATE: June 16, 2011 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Jefferson <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_ pre ceding _year,_new_distur -bances that am 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: Juliet A. Moores <br />Permittee Name: Elk Creek Sand & Gravel, LLC <br />Address: P.O. Box 416 <br />Conifer, CO 80433 <br />Phone Number: (303) 816 -4047 <br />Fax Number: <br />If you h.ve additi•nal comments and /or information that should be provided to the Division, please provide it <br />below or c �� this form along with your written report and map. Annual Report instructions are enclosed. <br />��` <br />Signature o Corpora - , C • • , .r designee <br />Date <br />RECEIVED s / <br />AUG 01 2011 <br />Division of Rectarnation, �/ <br />Mining and Safety �/ <br />