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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />ignature of orporate Officer, Owner, or Designee <br />Date <br />/D ,z0// <br />M:\PERMIT \MASTERDOCUMENTS\M -AF -04 <br />Bob Basher <br />Delta County <br />501 Palmer St Ste 227 <br />Delta, CO 81416 <br />(970) 874 -5914 <br />(970) 874 -2455 <br />NIT <br />ANNUAL FEE and REPORT REOUESTRECEIVED <br />Delta County <br />M- 1978 -168 <br />Pig Mesa Pit <br />October 26, 2011 <br />$791.00 (Due on or before your anniversary date) <br />Delta <br />SEP 6 2011 <br />,/ ©CT 1 I ZOU <br />/� Division at Reclamation , <br />Miting q1 <br />-According _to C.R.S. -34 -32.5- -1-1-6 -or- G.R.S.- 34- 32- -1 -1-6, -each year,-on- the - anniversary- date -of -the- permit, -an- <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning 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 <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred during the previous year and no <br />new changes to the previous year's map are necessary, then no new map is required, provided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />delineates and includes the 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 <br />enclosed. <br />i tt i cinvgr y <br />OCT 1 1 2011 <br />Divisi n of Reclamati <br />9 a safety <br />