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ANNUAL FEE and REPORT REQUEST ~ia~i C 9 ZOUb PERMITTEE NAME: Suburbau Sand & Gravel Co. t''` - ' '~~. M~.~~,~g a::d ~w;~.y PERMIT NO.: M-1979-195 OPERATION NAME: Road Runner Rest ANNIVERSARY DATE: January 28, 2007 ANNUAL FEE DUE: $$688.00 (Due on or before your anniversary date) COUNTY: Adams According to C.R.S. 34-32.5-116 or C.R.S. 34-32-1 l6, each year, on the anniversary date of the permit, an operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, reclamation accomplished to date-and during the preceding year, new disturbances that aze anticipated to occur dwing the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning of active operations, and the date active operations ceased for the year, if any. Please attach vour revised written annual renort and annual report maa to this form. The Annual Report & Fee requirement is not met until we Gave received the following components: fee. report. and associated IDBD. If no new disturbances or reclamation ha•: a occurred durine the previous veer and no uew chances to the urevious year's man are necessarv. then no new man is required. oroviued that the Operator shall state this in the Annusl Report. Please note that an adequately labeled map that clearly delineates and Includes the above elements may since for a wrrtren report. Division records indicate the following permittee contact information. Please verify and make any necessary changes: Permittee Contact: Dean H. Craft Pertnittee Name: Suburban Sand & Gravel Co. Address: 5400 Fenton St. Arvada, CO 80002 Phone Number: (303) 421-0720 Fax Number: (303) 467-0411 If you have additional comments and/or information that should be provided to the Division, please provide it below or attach it to this form along with your written report and map. Annual Report instructions are enclosed. Signature of Corporate Officer, Owner, or Designee Date