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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 coining 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: eta„ ua <br />Permittee Name: Elam Construction, Inc. <br />Address: 556 Struthers Ave <br />Phone Number: <br />Fax Number: <br />ignature <br />Date <br />ANNUAL FEE and REPORT REQUEST <br />c g- Elam Construction, Inc. <br />M- 1980 -085 <br />Vagneur Site <br />February 17, 2012 <br />$791.00 (Due on or before your anniversary date) <br />Pitkin <br />Grand Junction, CO 81501 -3826 <br />(970) 242 -5370 <br />(970) 245-7716 <br />c3(k VI <br />RECEIVED <br />'L FEB 1 20 . <br />7 6 Division of Reclamation, <br />Mining & Safety <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 />o •ora • • i' -r, Owner, or Designee <br />/y <br />