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r~ir~le- <br />/b ~S~k <br />e tvl l~ <br />,/ ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: /Tezak Heavy Equipment Co., Inc. <br />PERMIT NO.: ~M-1977-193 <br />OPERATION NAME: T.H.E. Aggregate Source <br />ANNIVERSARY DATE: November 22, 2006 <br />ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br />COUNTY: Fremont <br />~r,~ z ~, 205 <br />wi~~o~ of ~PCiTa etY n, <br />~ialininy'aod S <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each yeaz, 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 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 resort and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />man. If no new disturbances or reclamation have occurred durinc the previous vear and no new chances to <br />the previous year's map are necessary. then no new man is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adeguate[y 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: Daniel Tezak <br />Permittee Name: Tezak Heavy Equipment Co., Inc. <br />Address: 205 Tunnel Dr. <br />Canon City, CO 81212-3660 <br />Phone Number: (719) 269-1173 <br />Fax Number: (719) 269-1148 <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 />Signa re Corporate Officer, Owner, or Designee <br />/0 ~a0%00 ~ <br />Date <br />