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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />T i <br />r / ? <br />ANNUAL F E ana REPORT REQUEST <br />Za r Creek District Water Providers, EEC <br />004-067 <br />MMRR Quarry <br />R6 0 9 NIQ <br />Division Of R@@I§Msd@FR? <br />Jam, Mining & 5d <br />February 22, 2010 <br />$$791.00 (Due on or before your anniversary date) <br />Gilpin <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 />iE <br />--- _? operator ah'u?bm- it -the annual-fee,-a report and-iriap showing the extent of currenf di"sffrbances to affeae --land, reclamation accomplished to date and during the preceding <br /> 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: Robert A. Lembke <br />Permittee Name: Clear Creek District Water Providers, L.L.C. <br />Address: 5460 S. Quebec St., Ste 110 <br />Greenwood Village, CO 80111 <br />Phone Number: (303) 773-1005 <br />Fax Number: (303) 773-1176 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />be or attac it to this form along with your written report and map. Annual Report instructions are <br />Sign oorpo`v?e`ilfficer,Owner, or Designee <br />a) r? <br />Date <br />M:IPERMITIMASTERDOCUMENTS\N4-AF-04