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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />&A E and R P RT REOUEST <br />Lafarge West, Inc. <br />VM- 1980 -131 <br />Bunn Ranch Pit <br />November 15, 2009 <br />$791.00 (Due on or before your anniversary date) <br />Moffat <br />RECEIVED <br />t I NOV � 3 2009 <br />[Xv"n of RKWWR eR. ,, <br />—�D Kr&VanUfw <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 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 />Ma p . 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 O. Ray <br />Permittee Name: Lafarge West, Inc. <br />Address: 10170 Church Ranch Way, Ste. 200 <br />Westminster, CO 80021 <br />Phone Number: (303) 657 -4579 <br />Fax Number: (303) 657 -4037 <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 />h <br />Signature of Co orate Offii r, wner, or Designee <br />Date <br />