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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />4 P + 01- <br />ANNUAL FEE and REPORT REQUEST <br />Robert Daugherty <br />M-2004-048 ? <br />Cedar Point Picture Rock Quarry <br />October 4, 2009 <br />R[:-CC-6V[:-D <br />?--a51 <br />7i2?fdS <br />$323.00 (Due on or before your anniversary date) <br />San Miguel <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 />-- --recl%nation--accomplished-to--date-and-during the--preceding .year,-new- distur-banes-that_are_anticipated. 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 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: Robert Daugherty <br />Permittee Name: Robert Daugherty <br />Address: P.O. Box 1364 <br />Clifton, CO 81520 <br />Phone'Number: (970) 434-8773 <br />Fax Number: (970) 242-8438 <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. k,of4e S' Corpor e Offic ,Owner, or Designee <br />__ '9/'C/r'6 za <br />Dat