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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 />rectamati * . _ .. . ' _ . a e , • e • . ' . _ . - .. g n�v distu . , • - • . - .. .icippated 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 />Permittee Contact: Matt Alexander <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Name: E -470 Public Highway Authority <br />Address: 22470 E. 6th Parkway <br />Aurora, CO 80018 <br />Phone Number: 4343-)-5-3-7-34443. <br />Fax Number: (303) 537 -3472 <br />ior <br />ANNUAL FEE and R EPORT REQUEST <br />V E -470 Public Highway Authority <br />o' M- 1980 -110 <br />Henderson Development <br />September 9, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Adams <br />(30 53'7 = 3'121 <br />RECEIVED <br />AUG 2 4 2011 <br />Division of Reclamation, <br />Mining and Safety <br />11 ve <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 />S' nature of Corporate Officer, Owner, or Designee <br />Alf t 1 ac <br />Date <br />