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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 man 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 chances to <br />the previous year's man 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: John H. Bambei Jr <br />Same <br />Permittee Name: Denver Water Department <br />Address: 1600 W. 12th Ave. <br />Denver, CO 80204 <br />Phone Number: (303) 628 -6669 <br />Fax Number: (303) 628 -6851 <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 />1 <br />f . rporatefficer, Owner, or Designee <br />2912012 <br />A L FEE and R`PORT REQUEST <br />IA Denver Water Department <br />/M- 1979 -195 <br />Road Runner Rest <br />January 28, 2012 <br />$$791.00 (Due on or before your anniversary date) <br />Adams <br />Same <br />Same <br />Same <br />Same <br />Same <br />Same <br />ke Eiy _Er) <br />Olt/Won of . , ` . �� jl <br />hf c lanratton, <br />111009 & Safety <br />