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06 06:M tgiUM - U 6 i band and Stone 719 - 471 -9396 <br />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 - - 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 corning year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach our revised written annual re ort and annual re ort ma • 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 revious ear's ma are necess then no new rna is r aired rovided that the O erator 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 snake any necessary <br />changes: <br />Permittee Contact: William G. Johannsen <br />Permittee Name: <br />Address: <br />Phone Number: (719) 577 -9900 <br />Fax Number: (719) 471 -9396 <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 />$$323.00 (Due on or before your anniversary date) S atoiy <br />Belvedere Stone, LLC <br />C/o Ms. Ginna Kenley <br />2635 Steel Dr <br />Colorado Springs, CO 80907 <br />ANNUAL FEE and REPORT REQUEST <br />Belvedere Stone, LY,C <br />M 1991 - 147 <br />Belvedere Stone Quarry <br />July 16, 2012 <br />Douglas <br />6 K &NLEY <br />T -974 P0002/0002 F -763 <br />OCT 012012 <br />Divi <br />Mini & Reclamation, <br />