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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 />reciamatiorr - 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: Florence Jackson <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Signature of Corporat <br />Date <br />Canyon Rim Stone, LLC <br />27500 CR 183 <br />Kim, CO 81049 <br />(719) 643 -5435 <br />(719) 643 -5435 <br />A-K : ieifr <br />ANNUAL FEE and REPORT REQUEST <br />Canyon Rim Stone, LLC <br />«1V1- 2006 -053 <br />Canyon Rim Stone Quarry <br />August 31, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Las Animas <br />fficer, Owner, or Designee <br />/1 / 7 <br />RECEIVED <br />" AUG 1 5 2011 <br />Division �„ e�cnation, <br />pi' Mining and 8fety <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 />