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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 />- — — reclamation - accomplished -to -date -and during -the- preceding -year,- new- disturbances that occur <br />during the upcoming year, reclamation thafWilfbe performe 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 />man. 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: Bill Clark <br />Permittee Name: Grand <br />Address: <br />Phone Number: <br />Fax Number: <br />Date <br />P.O. Box 9 <br />Granby, CO 80446 <br />(970) 887 -2123 <br />(970) 887 -3168 <br />Signature gfCorporate Officer, Owner, or Designee <br />e R <br />ANN& FEE and REP RT REQUEST <br />QUES T <br />G nd County Department of Road & Bridge <br />- 2006 -029 <br />South Fork Gravel Pit (aka Williams Fork) <br />August 28, 2011 <br />$323.00 (Due on or before your anniversary date) <br />Grand <br />County Department <br />VAUG 24 2011 <br />.4.d ivision of Reclamation, <br />Mining and Safety <br />ii ql <br />of Road & Bridge <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 />