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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANN ffAFEt and PORT REQUEST <br />elvedere Stone, LLC <br />M-1991-147 <br />Belvedere Stone Quarry <br />July 16, 2010 <br />Y40- <br />WWAD <br />?JUL 16 2010 <br />Divan of RxckWWW, <br />4D L41 by "d <br />$$323.00 (Due on or before your anniversary date) <br />Douglas <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 may 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: William G. Johannsen <br />Permittee Name: Belvedere Stone, LLC <br />Address: C/o Ms. Ginna Kenley 6r I NN K Ke=W L& -/ <br />2635 Steel Dr <br />Colorado Springs; CO 80907 <br />Phone Number: (719) 577-9900 <br />Fax Number: (719) 471-9396 <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 />Signature of Co o to Officer, Owner, or Designee <br />--7 4151610 <br />Date