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ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: 7 Asphalt Constructors, Inc. <br />PERMIT NO.: JM-1977-053 <br />OPERATION NAME: Lyle Smith Pit ,/ Q s g <br />Lj 1j ANNIVERSARY DATE: December 23, 2010 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary ate) <br />COUNTY: Costilla <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 may 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 vear's map are necessarv, then no new map is reauired. 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 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: Todd A. Stockebrand <br />TIFFANY HAWKINS <br />Permittee Name: Asphalt Constructors, Inc. <br />Address: 7040 W US Highway 160 <br />Alamosa, CO 81101 <br />Phone Number: (719) 589-6671 <br />Fax Number: (719) 589-0927 <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 />aafiv A I W 41 A---) <br />re Corporate Officer, Owner, or Designee <br />Q4/ Z/( ---o / U <br />Date