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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 preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will 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: John H. Bambei Jr <br />Permittee Name: City & County of Denver acting by & thru Bd of Water Comms <br />Address: <br />Phone Number: <br />Fax Number: <br />Date <br />1600 W 12th Ave. <br />Mail Code 520 <br />Denver, CO 80204 <br />(303) 628 -6669 <br />(303) 628-6851 <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 />,4f <br />ANNUAL FEE and REPORT REQUEST <br />c f -. 94 & County of Denver acting by & thru Bd of Water Comms <br />V M- 2004 -078 <br />Lupton Lakes Resource CC / Vet) <br />October 17, 2011 aCr 122011 <br />$$791.00 (Due on or before your anniversary date) 1V 1 O o $ S l amq �� n , <br />Weld / afety <br />Officer, Owner, or Designee <br />