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PERMITTEE NAME <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />A 15' r <br />ANNA FEfE and 4PrORT REQUEST <br />Caldwell Brothers <br />(,M-1986-016 <br />Caldwell Brothers 3 <br />June 1, 2009 <br />ni= <br />j 1C <br />RECEIVED <br />#JUN 012009 <br />Division of Reclamation, <br />Mining and Safety <br />$$791.00 (Due on or before your anniversary date) <br />Otero <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 />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur <br />daring the-upcoming-year,-reelamat-ion-that wi-1l -be-per-formed-dur-ing-xhe_ 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 your 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 />map. If no new disturbances or reclamation have occurred during the previous Year and no new changes to <br />the previous year's map are necessary, then no new map is required, 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 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: Wayne Caldwell <br />Permittee Name: Caldwell Brothers <br />Address: 25026 Rd 19 <br />Rocky Ford, CO 81067 <br />Phone Number: (719) 254-3210 <br />Fax Number: <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 />'It" - IQ? - <br />Signatur of Corporate Officer, Owner, or Designee <br />Date