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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />M-2001-001 <br />Line Camp Pit <br />June 18, 2009 <br />JUN 2 4 2009 <br />D of %cl <br />Ml"g and 3??on, <br />$791.00 (Due on or before your anniversary date) <br />Montezuma <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 ar . anti .inated 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 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 vear's map are necessarv. 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: Kathy Stone <br />ANNUAL FEE and REPORT REQUEST <br />Four States Aggregates, LLC <br />Permittee Name: Four States Aggregates, LLC <br />Address: P.O. Box 1568 <br />Cortez, CO 81321-1568 <br />Phone Number: (970) 565-3388 <br />Fax Number: (970) 565-0276 <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 />-V)4C7?? _1_' az;?'C_2_ <br />Signature of Co orate Officer, Owner, or Designee <br />Date