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ACS a !G- <br />gr <br />ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: `trLogan County PERMIT NO.: "1-1987-159 /NOV 12 2009 <br />OPERATION NAME: Guenzi S & G Pit Division of Reclamation, <br />ff) Mining and Safety <br />ANNIVERSARY DATE: December 28, 2009 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Logan <br />_ __ __ According_t-C.R.S. 34-32.5-116 or C.R.S. 34_327116, 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 vear 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: Kris Pennington <br />Permittee Name: <br />Address <br />Logan County <br />315 Main St., Ste. 2 <br />Sterling, CO 80751 <br />Phone Number: (970) 522-7879 <br />Fax Number: (970) 522-4018 <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 />encloseed. <br />Signature of orpora e Officer, Owner, or Designee <br />f Nop Zc)o <br />Date <br />M:IPERMI'AN4AS TERDOCUMENTS\M-AF-04