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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: Edward J. Settle <br />Permittee Name: Grand Junction Pipe & Supply Co. <br />Address: <br />Phone Number: (970) 243- 4694 —=' <br />Fax Number: (970) 243 -6703 <br />Signature of Corporate Officer, Owner, or Designee <br />Date flq\ <br />Grand Junction, CO 81502 <br />1� r <br />AL FEE and ORT REQUEST <br />� // rand Junction Pipe & Supply Co. <br />.41-1978 -357 <br />Bradbury Pit <br />January 25, 2012 <br />$791.00 (Due on or before your anniversary date) <br />Mesa <br />7-3 /I El✓ ft <br />61(A-k4) . NC-7 - 70.-- ) j CO 8 (SvS <br />c7 b Z )4 S ' c) <br />� N 2 '7;'i! 12 <br />Mirun9 <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 />