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� .• 23- 04 -'11 08:38 FPO') -C & C Sand and Stone 719- 471 -9396 <br />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: fe 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: William G. Johannsen <br />Permittee Name: <br />Address: <br />Signature of Co <br />Date <br />Belvedere Stone, LLC <br />C/o Ms. Ginna Kenley <br />2635 Steel Dr <br />Colorado Springs, CO 80907 <br />Phone Number: (719) 577 -9900 <br />Fax Number: (719) 471 -9396 <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 />ate Officer, Owner, or Designee <br />ANN AY1 ')r, FEE and IQUEST <br />B Ivedere Stone, LLC <br />1991 -147 <br />Belvedere Stone Quarry <br />July 16, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Douglas <br />G t Y K &A,, Y <br />T -974 P0002/0002 F -763 <br />R CE V <br />RUG 052011 <br />�,L�iwaion of Reclamation, <br />7c' Mining and Safety <br />