2004-01-16_REPORT - M1977140

• Permit No: M1977140
• IBM Index Class Name: Report
• Doc Date: 1/16/2004
• Doc Name: 2004 Annual Report
• From: Mathias Concrete Inc.
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
JAN 1 62004
ANNiiAI, FF.F, and R~P9P~'~i~~~r~egtogY
Mathias Concrete, loc.
M-1977-140
N Farm Rd Pit No 1
January 15, 2004
JAN 1 ~ ."~Oq
®irision of Mia... -
- - ,;ealogY
$688.00 (Due on or before your anniversary date)
Rio Grande - 5
` ~Y./
According to C.R.S. 34-3Z.5-116 or C.R.S. 34-32-116, 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 are anticipated to occur
- -duringthe upcoming-year,-reclamation-that wi}1-be-performed during-the-eomingyear,-the-dates-for4he beginning -
ofactive operations, and the date active operations ceased for the year, if any.
Please attach your revised written annual rennrt and annual rennrt man to this form- Please note Iha1 an
adequately labeled map that clearly delineates and includes the above elements may suffice for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Thomas G. Mathias
Permittee Name: Mathias Concrete, Inc.
Address: 1500 N. Farm Rd.
P. O. Box 266
Monte Vista, CO 81144
Phone Number: [phone]
Fax-iiumberr-- (`7I9)-852~959

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 Offic _ ,Owner, or esignee
Date
M:\PERM IT\MASTERDOC UMENTSN1-AF-01