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P, <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Al\TNUAL FEE and REPORT REQUEST <br />Elbert County <br />?M-2001-056 <br />Belveal Gravel Pit <br /> <br />JQCT 2 ?- 2-003 <br />L.t ?sta> . CA <br />November 9, 2008 <br />$$323.00 (Due on or before your anniversary date) <br />Elbert <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 <br />operator shall submit the annual fee, a report-and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual report man to this form The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred durin the previous year and no <br />new changes to the previous year's map are necessary, then no new map is required, provided that the <br />Operator shall state this in the Annual Report Please note that an adequately labeled map that clearly <br />delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Tim Sheridan <br />Permittee Name: Elbert County <br />Address: 809 Ute Ave. <br />Simla, CO 80835 <br />i /1T 1A-/ <br />(719) 68 1 CA, <br />Phone Number: 541-22 <br />Fax Number: (719) 541-2826 <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 <br />enclos <br />'Signature of rporate tf rcer, Owner, or Designee <br />Date <br />M:\PERMIT\MASTERDOCUMENTS\M-AF-04