2012-01-27_REPORT - M1985210 (2)

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Permittee Contact: Douglas J. Bachli Permittee Name: PERMITTEE NAME: PERMIT NO.: OPERATION NAME: ANNIVERSARY DATE: ANNUAL FEE DUE: COUNTY: Address: C �� Phone Number: Fax Number: Rocky Road Investments P.O. Box 63 Masonville. CO 80541 (970) 203 -1072 (970) 669-8836 Signature $'Cop6rate Officer, Owner, or Designee =1 2 6 2 (Z Date I\ 4 ANNUAL FEE and REPORT REQUEST Rocky Road Investments /M- 1985 -210 Rocky Road Quarry January 27, 2012 $$791.00 (Due on or before your anniversary date) Larimer f f "If tit Ifs ('C. :r1, ;1( ;rte 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 shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning of active operations, and the date active operations ceased for the year, if an -y. Please attach your revised written annual report and annual report map to this form. The Annual Report & Fee requirement is not met until we have received the following components: fee, report, and associated map. If no new disturbances or reclamation have occurred during the previous year and no new changes to the previous year's map are necessary, then no new map is required, provided that the Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. Division records indicate the following permittee contact information. Please verify and make any necessary changes: If you have additional comments and/or information that should be provided to the Division, please provide it below or attach it to this form along with your written report and map. Annual Report instructions are enclosed.