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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />L"k aK- <br />-F <br />APdNUAL FEE and 61PORT REQUEST <br />ockbottom, LLC <br />M-1989-084 <br />Oak Creek Gravel Pit <br />CRIV <br />ibN 20 2010 <br />Div++WVfj u? KeClamilljOp, <br />--?V 11111149 end Safety <br />January 20, 2010 <br />$$791.00 (Due on or before your anniversary date) <br />Fremont <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 may 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 suf ce for a written report. <br />cords indicate the following permittee contact information. Please verify and make any necessary <br />i <br />Di <br />i <br />on re <br />v <br />s <br />changes: <br /> Andrew Kagan <br />Permittee Contact: Daniel M. Russell <br /> Rockbottom, LLC <br />Pennittee Name: Rockbottom, LLC <br /> 555 Ernest Avenue <br />Address: , <br />9042 S. 106 Rd. <br /> Alamosa, CO 81101 Westcliffe, CO 81252 <br />Phone Number: (719) 587-3630 719-783-9636 <br />Fax Number: <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 />ignature of orate Officer, Owner, or Designee <br />Date <br />M:\PERMIT\MAs'rERDOCUMENTS\M-Ar-04