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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 <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning 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 <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred during the previous year and no <br />new changes to the previous year's map are necessary, then no new map is required, provided that the <br />Operator shall state this in the Annual Report. Please note that an adequately labeled snap that clearly <br />delineates and includes the 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: <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <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 <br />enclosed. <br />Lei I d 4 I4# <br />Signature of Corporate Of er, • wner, or Designee <br />Date <br />t.c*o �zott <br />M:\PERMITNASTERDOCUMENTS\J AF -04 <br />Bill Hudick <br />Hudick Excavating, Inc. <br />160 County Rd 118 <br />Franktown, CO 80116 <br />(303) 204 -1431 <br />(303) 688-7314 <br />ANN FEE and RE ORT REOUEST <br />WI Iudick Excavating, Inc. <br />h- 1985 -129 <br />Elbert County Pit <br />November 25, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Elbert <br />J oIC 20449- <br />RECEIVED <br />1 / OCT 142011 <br />Division of Reclamation. <br />419 Mining SafetY <br />