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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 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 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 any necessary <br />changes: <br />Permittee Contact: Jon Hollenbeck <br />Ian GkAct e l' C o( inn. c1. h <br />Permittee Name: ACA Products, Inc. <br />Address: 702 Gregg Drive <br />P.O. Box 1887 <br />Buena Vista, CO 81211 <br />Phone Number: <br />Fax Number: <br />(719) 395 -3790 <br />(719) 395 -3794 <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 />4.k( 4 OhL-0,1/4- <br />Signature of Corporate Officer, Owner, or Designee <br />009k kq i?A'\ <br />Date <br />flv kh- <br />AL FEE and REPORT REQUEST <br />( V ACA Products, Inc. <br />M- 2005 -051 <br />River Park Recreation Access <br />November 14, 2011 <br />$323.00 (Due on or before your anniversary date) <br />Chaffee <br />R ECEIVED <br />✓ <br />NOV 0 ?2011 <br />fr) Uvielon of Reclamation <br />' <br />Mining & Safety <br />