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ANNIAL FEE and' t.EPOR QUEST <br />PERMITTEE NAME: V'Colorado Division of Highways 4 D A144 s <br />PERMIT NO.: I -1979 -142 <br />OPERATION NAME: West of Maybell Pit <br />ANNIVERSARY DATE: February 1, 2012 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Moffat <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 <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning 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 <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred during the previous year and no <br />new changes to the previous year's map are necessary, then no new map is required, provided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled map that clearly <br />delineates and includes the 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: Jeremy Lucero <br />Permittee Name: Colorado Division of Highways <br />Address: 222 S 6th St Rm 317 <br />Phone Number: (970) 683 -6223 <br />Fax Number: (970) 683 -6227 <br />Iii, p111ddiii0126 = <br />SAO writes or, in oonlrsri acrr�a.sr <br />or NW Ito sin+ - • ;arses d. <br />Grand Junction, CO 81501 <br />Do. hr. • r ' 000d! t 0".MoO <br />Signature o Corporate Officer, Owner, or Designee <br />�� /2_ 1/ <br />Date <br />M:IPERMIM4A5TERDOCUMENTS\M -AF-04 <br />or information that should be provided to the Division, please provide it <br />with your written report and map. Annual Report instructions are <br />"& r mare <br />y • AfA <br />