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ANNUAL FEE and REPORT REQUEST <br />PERMITI'EE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Nichols Gravel Pit, L.L.P. <br />M-1981-013 <br />Nichols Gravel Pit <br />October 21, 2002 <br />RECEIVEC <br />OCT 2 ~ ~~Z <br />Division of Minerals and Gaalogy <br />$688.00 (Due on or before your anniversary date) <br />Mesa <br /> <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 r~rt and map show4ng the extent_of_currenLdistucbances.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 vour revised written annual report and annual report map 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 [he following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: John Nichols <br />Permittee Name: Nichols Gravel Pit, L.L.P. <br />Address: P.O. Box 285 <br />Mesa, CO 81643 <br />Phone Number: (970) 268-5525 <br />- Fax-Number:--- ---(974) 268-5732 ----- -_- --- - - -- - - - <br />If you have additional comments and/or information [ha[ should be provided [o the Division, please provide it <br />below or attach it ro this form along with your written report and map. Annual Report instructions are enclosed. <br />Sign ure pf Corporate Officer, Owner, or Designee <br />0 oZ- <br />Date <br />M iPERMrM-tASTERDOCU h1ENTSU-I-AF-01 <br />