REP00036 ‎(3)‎

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ANNUAL FEE and REPORT REQUEST
PERMITTEENAME: Western Slope Construction Co FtFr'-jVED
PERMIT NO.: M-1983-209
OPERATION NAME: Benton Dawson Gravel
ANNIVERSARY DATE: July 25,2001 nivis,. 1 P:,i. l .'=ind Gaaleff
ANNUAL FEE DUE: $281.00(Due on or before your anniversary date)
COUNTY: Delta
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 shall submit the annual fee, a report and map showing the extent of current disturbances to affected
land, reclamation accomplished to date and during the preceding year,—new disturbances that are anticipated to
occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the
beginning of active operations, and the date active operations ceased for the year, if any.
Please attach your revised written annual report and annual report map to this form. Please note that an
adequately labeled nrap that clearly delineates and includes the above elements may suffice for a written
report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Jack L. Hawkins
Permittee Name: Western Slope Construction Co
Address: 1221 Hwy. 50
Delta, CO 81416
Phone Number: [phone]
Fax Number:
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are
enclosed.
�xnature of Corporate Officer or Owner
Date
M?PERM n-M ASTER DOCU M EN S\M-AF-01