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A-F- <br />ANNuAL FEE and REPORT REQUEST <br />PERMITTEE NAME: V))rth Weld Gravel <br />PERMIT NO.: 41 -1976 -018 <br />OPERATION NAME: North Weld Gravel +2 Mining and Safety <br />ANNIVERSARY DATE: October 17, 2011 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Weld <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 accompl.ished_to_date and_during_the_preceding_y_ear, 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 permi,ttee contact information. Please verify and make any necessary <br />changes: W b o2o /4 <br />Date <br />Permittee Contact: Leroy A. Bellmore <br />10 „ <br />Signature of Corporate Officer, Own <br />9 1- /7 <br />Permittee Name: North Weld Gravel <br />Address: 13480 WCR 100 <br />Nunn, CO 80648 -9700 <br />Phone Number: (970) 897 -2252 <br />Fax Number: <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 />or Designee <br />REcEmo <br />sV 14 7011 <br />Division of Reclamation, <br />