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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, 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: Gary Rinderle <br />Permittee Name: Gary Rinderle Construction, Inc. <br />Address: <br />Phone Number: <br />Fax Number: <br />Date <br />542 33 Rd. <br />P.O. Box 1380 <br />Clifton, CO 81520 <br />(970) 434 -0510 <br />(970) 434-6510 <br />Si i' . re of Corporate Officer, Owner, or Designee <br />G / AL FEE and REPORT REQUEST <br />'Gary Rinderle Construction, Inc. <br />/M- 2001 -088 <br />Upland Gravel <br />October 17, 2011 <br />$791.00 (Due on or before your anniversary date) <br />Mesa <br />RECEIVED <br />MMT272011 <br />Won Reolamatton, <br />*ling & Safety <br />32o SN.Set � f 0 <br />C D i.i+L - r -.J CO X,5 0 3 <br />If you have additional comments and /or information that should be provided to the Division, please provide it <br />below or attach it • this form along with your written report and map. Annual Report instructions are enclosed. <br />