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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <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- preeeding- year, —new- disturbances- thare anticipatcd to -oeeur <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 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: Stephen Kaspar <br />Permittee Name: <br />Address: <br />Phone Number: (970) 242 -5370 <br />Fax Number: (970) 245 -7716 <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 />Date <br />ANNUAL FEE and REPORT REQUEST <br />d Elam Construction, Inc. <br />/M- 1999 -076 <br />Highway 50 Borrow Area No. 2 <br />August 5, 2011 <br />$504.00 (Due on or before your anniversary date) <br />Mesa <br />Elam Construction, Inc. <br />556 Struthers Ave <br />Grand Junction, CO 81501 -3826 <br />Signature of ..rporate 0 lc- , e . er, or Designee <br />�/ ® Z <br />0// <br />P1/4F A- QPT <br />RECEfV E- Z <br />AUG 08 101 <br />Division of t eclamation, <br />Miring and Safety <br />