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x <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNWERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />A A FEE and PORT REQUEST <br />Washington County <br />vrl- <br />?-2000-084 <br />Chris Aaegeson Pit #2 <br />August 30, 2009 <br />.//RECEIVED <br />?Ul 29 2009 <br />Division of Declamation, <br />Mining and Safety <br />$$323.00 (Due on or before your anniversary date) <br />Washington <br />0?r__ <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 map 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 during 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: <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Jesse Stackhouse <br />Washington County <br />150 Ash Avenue <br />Akron, CO 80720 <br />(970) 246-3347 <br />(970) 345-2702 <br />?G Cc?c. ?c?S <br />w <br />C7 V <br />d Z <br /> <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 />enclosed <br />Si ature of Corp ate O ficer, Owner, or Designee <br />D <br />M: \PERMIT\MASTERDOCUMENTSUv1-AF-04