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ANNUAL AE and REPORT REOUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />d Boy Stone <br />I -1992-108 <br />Bad Boy Stone <br />February 3, 2010 <br />?kg <br />/9?C ® <br />,MAR 05 2010 <br />Division or Keciamabon, <br />fining and Safety <br />I <br />$$323.00 (Due on or before your anniversary date) <br />Boulder <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 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 may 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: Pablo Vasquez <br />Permittee Name: Bad Boy Stone <br />Address: 11493 WCR 20 <br /> <br />Fort Lupton, CO 80621 <br /> <br />Phone Number: (303) 857-4544 - d Z -? - 6 2 <br />Fax Number: (303) 772-9447 3 - 9 2 3 - 6 d ?9 <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 />- n3 Wv r 14,/ Lj QS ?&hC <br />ure f Corporate Officer, Owner, or Designee <br />Date <br />r + ' c. c. ev 2067 <br />nbA- aurt'i(?