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kls <br />~F~~i~T <br /> ANNiiAi, FF.F, and RF.PnRT R <br />~ F.t7ilF.CT <br />ECEIVED <br />R <br />PERMITTEE NAME: <br />PERMIT NO.: Select Materials <br />~/!CI-1980-205 ~ <br />~ yEP 2 <br />OPERATION NAME: Select Materials <br />als and GaolopY <br />i <br /> ner <br />~ Division of M <br />ANNNERSARY DATE: October 2, 2005 <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 or C.R.S. 34-32-1 lb, each year, on the anniversary date of the permit, an operator <br />`sfiall subinit the-annual fee,"a report aiia` 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 beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual re~nrt and anneal rennrt man 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 <br />changes: <br />Permittee Contact: Robert D. Oman <br />Permittee Name: Select Materials <br />Address: P.O. Box 280 <br />Phone Number: <br />Fax Number: <br />Fort Lupton, CO 80621 <br />(303)857-4688 <br />(303)857-4638 <br />If 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 />f //~~ ~Z(.~~..> <br />Signature of Corporate Officer, Owner, or Designee <br />~f l~~a~~ <br />Date <br />