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AN41ArFEE <br />and PO1T REOUEST <br />RECEIVED <br />)4-c <br />PERMITTEE NAME: dr Tracy and Ed Grimes <br />PERMIT NO.: 41- 2009 -077 `� 2011 <br />OPERATION NAME: Dill Pit lic)Divialoo of Roelomotloit, <br />Whig & Sof* <br />ANNIVERSARY DATE: October 20, 2011 <br />ANNUAL FEE DUE: $S323.00 (Due on or before your anniversary date) <br />COUNTY: Elbert <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 performedi 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: Ed Grimes <br />Permittee Name: Tracy and Ed Grimes <br />Address: 47570 Hwy. 24 <br />POBox399 <br />Limon, CO 80828 <br />Phone Number: (719) 775 -2524 <br />Fax Number: (719) 775 -2524 <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 />Signature of orporate.Officer, Owner, or Designee <br />/n 6 -/7 <br />Date <br />17N <br />