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(eCS <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />G ? <br />T- <br />"L FEE and REPORT REQUEST <br />?,-G. Everist, Inc. <br />t/M-1996-052 <br />Firestone Gravel Resource <br />MCOVW <br />A- G 0 2 2010 <br />Dh*on ®f f<,ci on, <br />ktyliftj and Sect! <br />August 4, 2010 <br />$$791.00 (Due on or before your anniversary date) <br />Weld <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 map 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: Dennis L. Fields V t? <br />I ,ia uvl& MAIA r S v <br />Permittee Name: L.G. Everist, Inc. <br />Address: 7321 E. 88th Ave., Ste 200 <br />Henderson, CO 80640 <br />Phone Number: (303) 287-4656 <br />Fax Number: (303) 289-1348 <br />A44- A <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 o orporate Officer, Owner, or esigne <br />n71,30 &M02 <br />Date <br />o%