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ANNUAL REPORT <br /> PERMITTEE NAME: Goose Haven Sand & Gravel, Inc. <br /> PERMIT NO.: M-1984-099 <br /> OPERATION NAME: Bailey Pit <br /> ANNIVERSARY DATE: September 29, 2000 <br /> ANNUAL FEE DUE: $688.00(Due on or before your Anniversary Date) <br /> COUNTY: Weld <br /> According to C.R.S. 34-32.5-116(3)(a), each year, on the anniversary date of the permit, an operator shall submit <br /> the annual fee, a report and map showing the extent of current disturbances to affected land, reclamation <br /> accomplished to date and during the preceding year, new disturbances that are anticipated to occur during the <br /> upcoming year, reclamation that will be performed during the coming year, the dates for the beginning of active <br /> operations,and the date active operations ceased for the year, if any. <br /> Please attach your revised annual report may and written report to this annual report. Please note that an <br /> adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br /> Please type or print the current contact person's name, mailing address, and phone number in the space provided: <br /> Contact Name: Company. <br /> Address: Phone No.: ( ) <br /> FAX No.: ( 1 <br /> e-mail: <br /> If you have additional comments and/or information that should be provided to the Division, please provide it on <br /> the back of this report form along with your map and written report. <br /> Signature of Corporate Officer, or Owner Date <br />