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PERMITTEE NAME: 41l C ntennial State Paving, Inc. <br />PERMIT NO.: 17M-2007 -069 Division ut 0 ...mootat ion, <br />49 Mining and Safety <br />OPERATION NAME: Pheasant Run Gravel Pit <br />ANNIVERSARY DATE: July 10, 2011 <br />ANNUAL FEE DUE: $5791.00 (Due on or before your anniversary date) <br />COUNTY: Pueblo <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 />operator shall submit the annual fee, a report and map showing the 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: James Bartmess <br />Permittee Name: Centennial State Paving, Inc. <br />Address: f035 E Northern Avenue <br />Pueblo, CO 81001 <br />Phone Number: (719) 948 -2000 <br />Fax Number: (719) 948 -2121 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below _ attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />nature of Corp ate Officer or Owner <br />/ (' <br />'W <br />Date <br />• <br />s <br />ANN{JAL FEE and REPORT REQUEST <br />s �. <br />F;ECE,n►ED <br />AI If,12 2011 <br />