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f 5A <br />ANNUAL FEE a`nd P RT REQUEST <br />PERMITTEE NAME: Grand County Department of Road and Bridge / <br />PERMIT NO.: :?VI-2009-064 <br />OPERATION NAME: CR #3 Pit _[Jv'? i r ; " ^,-'.!on, <br />ANNIVERSARY DATE: December 11, 2010 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Grand <br />D /L <br />According-to-C.R:S. -34-3-2-:5-146- or E.RS: 34-32--1-1.6, each-year,-on the- anniversary-date-of-thv-perniit air-- -- -- <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 chances 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 ivritten report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Ken E. Haynes <br />Permittee Name: Grand County Department of Road and Bridge <br />Address: P.O. Box 9 <br />Phone Number: <br />Fax Number: <br />Granby, CO 80446 <br />(970) 887-2123 <br />(970) 887-3168 <br />If you have additional comments and/or information that should be provided to the Division, please provide it <br />below or attach it t this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />i <br />Signature of Corporate O icer, Owner, or Designee <br />l l /2y?2 n !0 <br />Date <br />M:\PERA41T,J STERDOCUMENTS\M-AF-04