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~ Y" / <br />~- ~ / ~~~ <br />ANNiJAL FEE and REPORT REQUEST <br />PERMITTEE NAME: ~ Goose Haven Sand & Gravel, Inc. <br />PERMIT NO.: ~-1984-099 <br />OPERATION NAME: Bailey Pit <br />ANNNERSARY DATE: September 29, 2007 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Weld <br />R~cFw~D <br />- oCr ~ ~ ?001 <br />D/ivisia,1 ~ <br />V M"t'~ @~~~H+ <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 operator <br />shall submit the annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation acw~lished 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 vour revised written annual report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, resort, and associated <br />maa. If no new disturbances or reclamation have occurred durinc the previous vear and no new chances to <br />the previous year's moo are necessary, then no new moo is required. provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Doug Tiefel <br />N® C_~n.wn~~z.s y~ vim <br />Permittee Name: Goose Haven Sand & Gravel, Inc. ~~'~ d-~~ ~ $'~ a~«~ <br />Address: P.O. Box 17130 <br />Boulder, CO 80308 ~. `~s-G~~~'~" 't-~`r 5~~~-~~e <br />Phone Number: (303) 665-9390 <br />Fax Number: (303) 665-0165 <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 />~Qf1~ L tE.i`~-mil ~'1'-¢.~ <br />Signature of Corporate Officer, Owner, or Designee <br />~ZL7~~? <br />Date <br />