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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Tezak Heavy Equipment Co., Inc. <br />M-1977-193 <br />T.H.E. Aggregate Source <br />November 22, 2003 <br />OCT 3 01003 <br />Division of Minerals and Geology <br />$688.00 (Due on or before your anniversary date) <br />Fremont <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 />ual-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 ynnr revised written anneal re~nrl and annual rennrt man to this Tnrm_ 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: Daniel Tezak <br />Permittee Name: Tezak Heavy Equipment Co., Inc. <br />Address: 201 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 ii to [his form along with your written report and map. Annual Report instructions are enclosed. <br />Signa e f Corporate Officer, Owner, or Designee <br />t'o• a s- 03 <br />Date <br />M:W Eft M ITU4ASTERD000M ENTS~hI-AF-01 <br />