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..~ <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br /> <br />ANNUAL FEE and REPORT REQUEST <br />Tezak Stone &Aggr Supply, Ioc. <br />M-1981-080 <br />Tezak No 2 Pit <br />May 27, 2001 <br />$225.00 (Due on or before your anniversary date) <br />Fremont <br />RECE~ VED <br />MAY 3 1 1001 <br />Division of Minerals and Geology <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land; reclamation-accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual report and annual resort maa to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elemer:rs may suffice for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact Mike A. Tezak <br />Permittee Name: Tezak Stone &Aggr Supply, Inc. <br />Address: 6200 CR 37 <br />Texas Creek, CO 81223 <br />Phone Number: (719) 275-1146 <br />Fax Number: (719) 275-1146 <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 <br />enclosed. <br />~"i' .l/ <br />Signature of Corporate Officer or er <br />S ~a7 /o/ <br />Dale ~ <br />M ~PERM77V.1ASTERDOCUMEMSUI-AF-01 <br />