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<br />PERMITTEE NAME: Rock-N-Pine LLC <br />PERMIT NO.: M-2003-074 ~ • ~l " "~.~ <br />OPERATION NAME: Rock-N-Pine .,y,,,Sinn of l roar' 1` Frnfno~~ <br />ANNIVERSARY DATE: February 5, 2005 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) ~J~ <br />COUNTY: Park <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 />- - - - reclamafori accomp~~s"'lied-To date arid-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 ynnr revised written anm~al re~nrt and annual report m ~ to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the 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: Mark Balderson <br />Permittee Name: Rock-N-Pine LLC <br />Address: P.O. Box 1793 <br />Breckenridge, CO 80424 <br />Phone Number: (719) 836-9863 <br />Fax Number: (719) 836-9863 <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 Corporate Officer, Owner, or Designee <br />Date <br />