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PERMITTEE NAME: A7kson County <br />PERMIT NO.: ( -266 <br />OPERATION NAME: Riley Gravel Pit <br />ANNIVERSARY DATE: August 15, 2011 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Jackson <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 <br />operato shall- submit-the- annual fee, - a-report and-map 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 map 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 map 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: <br />Permittee Name: Jackson County <br />Address: P.O. Box 488 <br />188 Grant Street <br />Walden, CO 80480 <br />Phone Number: (970) 723 -4481 <br />Fax Number: (970) 723 -8437 <br />AL FEr and zPORT REQUEST <br />R CEIVED <br />400 02 Nil <br />��ivi of Reclamation <br />afety <br />M <br />No �4f17P <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 />encl <br />Signature . Corporate Officer, Owner, or Designee <br />Date (V1i <br />M:IPERMMMASTERDOCUMENTS\M -AF -04 <br />