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PERMIT"TEE NAME: <br />PERMIT NO,: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: -PeterM. K-earl- Jason Burkey <br />Address: <br />Phone Number: <br />Fax Number: <br />P.O. Box 3609 <br />Grand Junction, CO 81502 <br />(970) 243-4900 <br />Signature ,6f Corporate OilFlcer, Owner, or De ee <br />D / / «f .20/2- <br />Date <br />/`- Air / <br />A A L F EE a nd REPORT REOUEST <br />l <br />A-Ol castle SW Group, Inc. dba United Companies of Mesa County <br />-1977-132 <br />Berry Pit <br />January 16, 2012 <br />$791.00 (Due on or before your anniversary date) <br />Rio Blanco <br />RECEIVED <br />` JJAN' (. <br />� ivision rrt Reclamation <br />/ v M,ning & Safety <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 man to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />rnap. If no new disturbances or reclamation have occurred during the nreviousyear 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 since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Name: Oldcastle SW Group, Inc. dba United Companies of Mesa County <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 />