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r19/c-- <br />GG-S <br />V?NUAL FEE and REPORT REQUEST R-CLRVED <br />1LL 2 2009 <br />PERMITTEE NAME: ?PILEverist, Incorporated <br />PERMIT NO.: Dhftim of Recl@m&fiom, <br />Miring and Safety <br />OPERATION NAME: Firestone Gravel Resource p <br />ANNIVERSARY DATE: August 4, 2009 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Weld <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 />-during=the-upcommggear,--reelamation=that will-be_per_formedduring_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 reauired, 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 since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Lynn M. Shults <br />+' A <br />Permittee Name: L.G. verist, Incorporated 69-?17 <br />Address: 7321 E 88th Ave., Suite 200 <br />Henderson, CO 80640 <br />Phone Number: (303) 286-2247 <br />Fax Number: (303) 289-1348 <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 />Signature of Corporate Officer, Ow , or esign <br />4711 <br />Date