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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: Jason Burkey <br />A ddress: P.O. Box 4870 <br />Phone Number: (970) 328 -1734 <br />Fax Number: (970) 328 -1735 <br />September 8, 2011 <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 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 />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 Name: Oldcastle SW Group, Inc. d.b.a. B & B Excavating <br />Eagle, CO 81631 -4870 <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 />Signatuv of Corpora fficer, Owner, or Designee <br />9/.20,// <br />Date <br />I f <br />ANNUAL F EE and ORT Q ST <br />`-,., Oldcastle SW Group, Inc. d.b.a. B & B Excavating <br />(/M 1997 -026 <br />Carol Ann Pit <br />tat <br />1-0 oiSFP 8 ?oil <br />$791.00 (Due on or before your anniversary date) pgi pin� / <br />Eagle <br />