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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: Craig Tessmer <br />Permittee Name: ms ounty <br />Address: S r5 - E: 74Th Ave. <br />Date <br />Ge I -eity, CO <br />Phone Number: .(303) 853- -700 -� <br />Fax Number: X3.03 53-71 T5'� <br />Signatur: • ` S •rporate Officer Owner, or Designee <br />M:IPERMITIMAS TERDOCUMENTS\M -AF -04 <br />ANNUAL FEE anREPORT QUEST <br />A dams County <br />61-1977 -283 <br />Debetz Pit <br />December 21, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Adams <br />De c 4 <br />D hlyon of 20 <br />+ & Safe an on. <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 />ve.AvoloL v r <br />4430 So 0 +L Alc4u5 W i P/1-41,31)- - r <br />i S fLUVr2, S'v (rF \V ZaaA <br />c5bc0O( <br />•7Z((,5Z3U' <br />7200 6Z 3, U f f B <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 />e� : ed. <br />