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<br />Rip k ef-r <br />ANNUAL FEE and REPORT REOUEST <br />PERMITTEE NAME: Wagner Construction, Inc. RECEIVED <br />PERMIT NO.: M-1999-018 APR 01 2011 <br />OPERATION NAME: Wagner Rock nivlalafl of Roolamation, <br />ANNIVERSARY DATE: April 20, 2011 ??% Mining Safety <br />ANNUAL FEE DUE: $323.00 (Due on or before your anniversary date) <br />COUNTY: Moffat <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 wil"i be perf6rmed-duffing fne chmmg year; a as es- o-r egirining <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 man 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 may 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: Jay L. Wagner <br />Permittee Name: Wagner Construction, Inc. <br />Address: 1850 E. Ist Street <br />Craig, CO 81625 <br />Phone Number: (970) 824-2709 <br />Fax Number: (970) 824-2709 <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 />ZIZ <br />ature of C orate Officer, Owner, or Designee <br />+I-11' <br />Date