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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNZ7A FEE `and REPORT REQUEST <br />Pi remont County / <br />Y - <br />M-1979-216 <br />Dist No 2 Gravel Pit YT <br />January 20, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Fremont <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 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 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: Gary Weirton <br />Permittee Name: Fremont County <br />Address: 615 Macon Ave., Rm. 105 <br />Canon City, CO 81212 <br />Phone Number: (719) 784-6474 <br />Fax Number: (719) 275-7626 <br />Paul Garrett <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 />enclo d. <br />r <br />Signature oofforporate Officer, Owner, or Designee <br />la//-? /.rQ o?0 <br />Date <br />M: \PERMITIMASTERDOC UMENTS\N4-AF-04