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~~ Y ~~ <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Four States Aggregates, LLC <br />l~M-1990-025 <br />Hay Camp Pit <br />May 22, 2007 <br />~,°~~ "' et h"" <br />qq~p <br />0~ slonofRecla~on <br />Mining and Sa <br />$$688.00 (Due on or before your anniversary date) <br />Montezuma <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~~e,_a_re}~ort_and_map~hovting_the_extent_occurrent_dish~rbances-to-affecked-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 vour 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 />ma If no new disturbances or reclamation have occurred during the previous vear and no new chances to <br />the previous year's map are necessary, then no new map is reuuired, 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 since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: ~ <br />~t~'~1~~2 <br />Permittee Name: Four States Aggregates, LLC _ <br />Address: P.O. Box 1568 <br />Cortez, CO 81321-1568 <br />Phone Number: (970) 565-3388 <br />Fax Number: - ~~ b ` ~ S ~ b'~~ 10 <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 />~~ <br />Signature of Corp rate Officer, Owner, or Designee <br />~~ ~~ <br />Date <br />