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PERMTITEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />13olcim (US) Iuc. <br />M-1977-344 <br />Portland Limestone Quarry <br />October 10, 2005 <br />$688.00 (Due on or before your anniversary date) <br />Fremont <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 yeaz, 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 yeaz, if any. <br />Please attach ynnr revised written annnal re~nrt and annual report main to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Michael E. Gantenbein <br />Permittee Name: Holcim (US) loc. <br />Address: 3500 Hwy. 120 <br />Phone Number: <br />Fax Number: <br />Florence, CO 81226 <br />(719)784-6325 <br />(719)784-1213 <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 Corporate Officer, Owner, or Designee <br />Date <br />