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e-c- s <br />b <br />AN AL FEE a6 REPORT REQUEST CEIVECp <br />PERMITTEE NAME: ma County Road and Bridge D/vlslun at <br />l'Ic? <br />r R ?y <br />PERMIT NO.: Z--2009-070 <br />N a•1 ?Y?j yam./ <br />OPERATION NAME: Witherbee Pit d <br />ANNIVERSARY DATE: November 3, 2010 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Yuma <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 />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 vour 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: Mark Shaw <br />Permittee Name: Yuma County Road and Bridge <br />Address: 1310 South Blake Street <br />Wray, CO 80758 <br />Phone Number: <br />Fax Number: <br />(970) 332-5718 <br />(970) 332-3429 <br />?OW R R ci n'1 G V'I rd jt?i,3' <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, or Designee <br />/0 -a/ -/D <br />Date <br />M: TERMITIMASTERDOCUMENTS\M-AF-04