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~~~ ~ <br />F~~` § <br />ANNiiAi, FFF, and RFPnRT RFnIIEST ~~~- <br />/~ ~u~ o a 2ao~ <br />PERMITTEE NAME: Jordan C. and Jone L. Burdick <br />// ,trv~sion of p~ticarsls & GaclopY <br />PERMIT NO.: /M-1987-092 <br />OPERATION NAME: B & G Stone <br />ANNNERSARY DATE: August 25, 2005 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Larimer <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 t_he annual fee a reuort and ma~showine the extent_occurrent_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 re~nrt and annual re,Rprt main, to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may Buff ce far a written report. <br />Division records indicate the following percnittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Jordan C. Burdick <br />Permittee Name: Jordan C. and Jone L. Burdick <br />Address: P.O. Box 1385 <br />Lyons, CO 80540 <br />Phone Number: (303) 823-5943 <br />Fax Numherr - ~ - - ~ -~: - <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 />L ,.f/I <br />ignature o/f Corporate Office ,Owner, or Designee <br />D ~-- ©rS_ <br />Date <br />