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<br />A / QUEST 'R?CEIVE'C? <br />A LFEi and?_-REPORT? RE <br />?AR 10 2011 <br />PERMITTEE NAME: 'irman Brothers LLC <br />j DIVISIOn of & Safety no <br />PERMIT NO.: 95-009 -?f <br />OPERATION NAME: Fasse Pit <br />ANNIVERSARY DATE: April 5, 2011 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Kit Carson <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 durin the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclamation that will be performed during the commg year, tfie Gates for the- ieginning <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: MichaelJ3. Do an <br />Permittee Name: Dorman Brothers LLC <br />Address: 19230 County Rd. 55 <br />Burlington, CO 80807 <br />Pho=umber: (719) 3 6-7970 <br />Fax /1 (71 346-7971 <br />you have i comments / r 'nforma 'o that should be provided to the Division, please provide it <br />low or a i to is forma] i our writt report and map. Annual Report instructions are enclosed. <br />r <br />,,of Corporate fficcz,,Owner, or Designee <br />re