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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, ucw disturbances - that are antidpated t"o occur <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: John Nichols <br />Permittee Name: Nichols Gravel Pit, L.L.P. <br />Address: P.O. Box 285 <br />Mesa, CO 81643 <br />Phone Number: (970) 268 -5525 <br />Fax Number: (970) 268 -5732 <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 />Si:'tture of Corporate Officer, Owner, or Designee <br />Date <br />ANNUAL FEE and REPORT REQUEST <br />Nichols Gravel Pit, L.L.P. <br />M- 1981 -013 <br />Nichols Gravel Pit <br />October 21, 2011 <br />$791.00 (Due on or before your anniversary date) <br />Mesa <br />O aitiv(/‘. <br />RIECEAM <br />-/ OCT i 9 2011 <br />g Division or r<ecfamation, <br />Mining and Safety <br />