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M 4 2f <br />ANNUAL FEE and REPORT REQUEST <br />c 2 <br />PERMITTEE NAME: ✓ Grand Junction Concrete Pipe Co. <br />PERMIT NO.: M- 2009 -048 ,/ 5-Esa 1 <br />OPERATION NAME: Gunnison River Gravel Pits '� <br />ANNIVERSARY DATE: September 28, 2011 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Mesa <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 />r cclwwnation- ace • - • • . v • • V diStarbanCeb that urG a d i t i e t p a t e d to oCt - - <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 permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Edward J. Settle <br />' An) D G-� <br />Permittee Name: Grand Junction Concrete Pipe Co. <br />Address: P.O. Box 1849 <br />Grand Junction, CO 81502 <br />Phone Number: (970) 245 -9301 <br />Fax Number: (970) 243 -6703 <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 />z <br />Signature o Corporate Officer, Owner, or Designee <br />z <br />Date <br />