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YT ~ <br />PE[L~tITTEE NA,~(E: <br />PERbIIT NO.: <br />OPERATION NAb1E: <br />ANNIVERSARY DATE: <br />A,~Ni UAL FEE DUE: <br />COUNTY: <br />~~`~r~- <br />Lafarge West, Inc. <br />-a1~3-~ ( <br />~ocktiX~.~l P;~ <br />I~~av. ~~~~J <br />C%~M <br />,~ <br /> <br />5688.00 (Due on or before your anniversary date) <br />Cl~~d <br />According to C.R.5. 34-32.5-116 or C.R.S. 34-32-116, each yeac, on the anniversary date of the permit, an operator <br />shall submit the annual tee, 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 be, nning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach ynnr reviced written annnal rennrr and anm,al resort man to chic form. Please nOle that an <br />adequately labeled map that clearly delineates and inck,des dre above elements may st ff ce for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Eric Reckentine <br />Permittee Name: Lafarge West, Inc. <br />Address: 1400 W. 64th Ave. /O17D C~Zt,/C)'1~ndh lA~. n <br />~5, ~~-~P ~[X~ <br />Denver, CO 30221 tl.~°.5~7n~n r ~~ ~~ <br />Phone Number: (303) 65 i-1330 (3n3) (0.~7 ~ U ~~() <br />Fax Number: (303) 637-4339 17iO3~~e.~J7" LlD3~ <br />[f 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 />~ > ~.~~~ <br />Signature ofCorporate Ofticer, Owner, or Designee <br />v <br />ll ~IPr~t~6P~ ~1 ~an.~ <br />Date <br />