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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 <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 />Permittee Contact: <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Date <br />Randy Renquist <br />Sedgwick County <br />223 S Cedar <br />Julesburg, CO 80737 <br />(970) 474 -3576 <br />(970) 474 -3558 <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 />M:IPERMITIMAS TERDOCTJMENTS\M -AF -04 <br />Signature of Corporate Officer, O0Gner, or Designee <br />AN AL FEE and REPORT REQUEST <br />l Sedgwick County <br />4-1996 -073 <br />Dolezal Gravel Pit <br />November 8, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Sedgwick <br />ROOMED <br />OCT 2 7 2099 <br />ecs 8 ,L <br />Latigoion of Reclamotion <br />& &far <br />