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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: Mark Yevoli <br />Permittee Name: Yevoli Cobblestone Inc <br />Address: 10001 Astoria Ct. <br />Lone Tree, CO 80124 <br />J3-- - 4 ,30`Z- <br />Phone Number: (303) 912 -1800 <br />SC 4 /7/ / ZSE <br />Fax Number: <br />Date <br />AN NUA REPORT REQUEST <br />Yevoli Cobblestone Inc <br />/M-2007-003 <br />FEE and R <br />Yevoli Cobblestone Pit <br />September 6, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Fremont <br />RECEIVM <br />/AUG 10 2011 <br />Division of Reclamation, <br />Mining and Safety <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 acscompiished and - during -thc-piec,eding=year, disturbances -that 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 />If you have comments and /or information that should be provided to the Division, please provide it <br />or belo form along with your written report and map. Annual Report instructions are enclosed. <br />Si ature of ' orporate Offic r, Owner, or Designee <br />