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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: Sarah L. McNulty <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Date <br />5ARA4- L . M ` W U LTI <br />Quarter Circle 8 LLLP Ca.tt k etee 1 et � <br />7747 Country Road 100 11 141 ' C ? J . Lao <br />Czab <br />Cam• 'I(23" <br />Carbondale, CO 81623 <br />(970) 963 -4363 <br />I / 24 . <br />AN4UAL FED and REPORT REQUEST <br />.- Quarter Circle 8 LLLP <br />rvI- -1980 -003 <br />)Division of Reci,:niaton, <br />McNulty Cinder Pit tvlm nn & S : <br />January 23, 2012 <br />$323.00 (Due on or before your anniversary date) <br />Eagle <br />q ` I V Ct: <br />Signature of Corporate Officer, Ow r, or Designee <br />RECEIVE <br />A 42 <br />6 170 Ci 63 )-3 43 <br />S rt fir <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 />7 are {/I& cL e- : (°usk e )4; ntem..1.ep 1e W1am.' I sw'RR <br />