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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 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: Patricia Farnsworth <br />Permittee Name: Farnsworth <br />Address: 175 Hwv 133 <br />Paonia, CO 81428 <br />Phone Number: (970) 527 -4434 <br />Fax Number: (970) 527 -5522 <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 />4101r , / <br />Signa of Corporate Officer, Owner, on esignee <br />Date <br />d -«4 <br />ANNUAL FEE and REPORT REQUEST <br />âś“Farnsworth Construction and Gravel Company <br />/ M- 1982 -154 <br />Farnsworth Gr Pit 2 <br />November 5, 2011 <br />$323.00 (Due on or before your anniversary date) <br />Delta <br />Construction and <br />NOV 03Z011 <br />plvis;on of Reclarr on, <br />piing and Seri* <br />Gravel Company <br />