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PERMITT :[NAME: <br />PERMIT N <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: Lynn M. Shults <br />Mcifit <br />Permittee Name: L.G. verist , Inc. <br />Address: 7321 E. 88th Ave., Ste 200 <br />Henderson, CO 80640 <br />Phone Number: (303) 286 -2247 <br />Fax Number: <br />Signature of Corporate Officer, Owner, or Designee <br />Date <br />ANNi7A`L FEE. and RA‘ REQUEST <br />/ L G. Everist , Inc. <br />l/ M- 1988 -048 <br />Carr Gravel Resource <br />September 22, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Weld <br />°_c 5 <br />SEP 11, 2011 <br />®i!llSi�fY �, .+.ua,,�'vYitYif.t, <br />Mining and SafaV <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 reclamation - that will performed during the coming year; the dates 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 permittee contact information. Please verify and make any necessary <br />changes: <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 />