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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 receding_y_ear, _ne� disturbances that are anticipated to occur <br />burin th Inc om ag year reclamation that will be perform me urin$ the coming year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />- - 1 <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 shill 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: David Curtis <br />Permittee Name: Oaklands Ranch <br />Address: 1613 N Perry Park Rd <br />Phone Number: <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 attac to this form along with your written report and map. Annual Report instructions are enclosed. <br />Sign . Hof Corporate Officer, Owner, or Designee <br />Date <br />— Sedalia, - CO -- "801358511 -- <br />(303) 688 -4285 <br />(303) 688 -7957 <br />14C- <br />ANNIfEFEE ind REPORT REQUEST <br />aklands Ranch <br />i <br />- 1989 -092 <br />Oaklands Ranch <br />October 26, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Douglas <br />L Fp 1 4 7nii <br />Division �I 9f <br />i end Safety <br />