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0,V,VA ?qr ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: ? Dolores County Road & Bridge Dept. <br />PERMIT NO.: / M-2008-020 <br />OPERATION NAME: / Pribble Pit <br /> <br />? AUG 0 2 2010 <br />?p Di n ear ROciOrrm0on <br />C/ Mining and Sakoy <br />ANNIVERSARY DATE: August 4, 2010 <br />ANNUAL FEE DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY: Dolores <br />-- According°to-C.R.S. -3-4 -32-."- 16 or C.R:S: 34=32=116e, ach yer, on the annivers date of-the ermrt 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 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 since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Tim Huskey <br />Permittee Name: Dolores County Road & Bridge Dept. <br />Address: 1010 N. Guyrene <br />PO Box 608 <br />Dove Creek, CO 81324 <br />Phone Number: (970) 677-2328 <br />Fax Number: (970) 677-3759 <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 />Signature of Corporate Officer, Owner, ignee <br />Date <br />M:IPERMITIMASTERDOCUMENTS\M-AF-04