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ANNUAL FEE and REPORT REQUEST <br />PERMITI,EE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Holnam, Inc. - Ft Collins Plant <br />M-1977-345 <br />Boettcher Sandstone Quarry <br />October 10, 2002 <br />$688.00 (Due on or before your anniversary date) <br />Larimer <br />~E~~EI V ~® <br />®CT 0 3 ~00~ <br />9ioisian of P,2^.'rxrnls and feolog;~ <br />According to C.R.S. 34-32.5-I 1 6 or C.R.S. 34-32-1 16, 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, 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 written annual reuort and annual report map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary changes: <br />Permittee Contact: Gordon Benton, Project Manager <br />Permittee Name: Holnam, Inc. - Ft Collins Plant <br />Address: P.O. Box 1548 <br />Phone Number: (970) 482-4065 <br />Fax Number: (970) 482-1363 <br />If you have additional comments and/or information that should be provided to the Division, please provide it below or <br />attach it to this form along with your written report and map. Annual Report instructions are enclosed. <br />Signature of rpo to Offt r, caner, or Designee <br />Date ~~/ Z/ 03 <br />