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AF +- QP-r <br />ANNUAL FEE and REPORT REOUEST <br />4AR , <br />PERMITTEE NAME: -( Benson Brothers ©J'?dn .9 (0/, <br />PERMIT NO.: ? M-2004-084 ?n'?9 roc, <br />OPERATION NAME: Benson Brothers Pig Mesa Pit o on <br />ANNIVERSARY DATE: May 5, 2011 <br />ANNUAL FEE DUE: $791.00 (Due on or before your anniversary date) <br />COUNTY: Delta <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 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 necessarv. then no new man 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: Ed Benson <br />Permittee Name: Benson Brothers <br />Address: 21240 Austin Rd <br />Phone Number: <br />Austin, CO 81410 <br />(970) 835-3128 <br />Fax Number: (970) 835-8567 <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 />J <br />Signature of Corporate Officer, wner, or Designee <br />Date <br />RECEIVED <br />APR 29 Division of Reclamation, <br />Mining & Safety