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IB-OCT-2005 08:11 FR00-Colorado DIvlclon of llinarals 6 GaolaBr f1303B328106 T-B1B P.003/003 F-160 <br />ANN(TAi.l4'F.F. and RF.Pt1RT R12(~iTF.ST <br />Pk:RMITTEE NAME: SW Chambers, LLC <br />PERMIT NO.; M-2003-016 <br />OPERATION NAME: Heir Sand and Gravel Mine <br />ANNIVERSARY DATE: September 27, 2005 <br />ANNUAL FEE DUE: $688.00 (Dnc on or before yonr anniversary date) <br />COUNTY: Weld <br />According ro C.R.S. 34-32.5-I 16 or C.RS. 34-32-t t6, 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 cumnt duttubances to affected land, <br />reclamation accomplished to date and dtuing the precedmg year, new distwbances that arc anticipated to occur <br />duriog the upcondng 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 aftnrb~nnr revised written annual rnnort and annnai repy~t map to fhit Fnrm. Please note That an <br />adequately labeled map that clearly delineates and includes the above elements may s~ce for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any accessary <br />changes: <br />Permittee Contact: Mark D. Campbefl <br />Pemtittce Name: SW Chambers, LLC <br />Address: 333 W. Hampden Ave., S[c 810 <br />Englewood, CO 80110 <br />Phone Number: (303) 534-1040 <br />Fax Number. <br />303 --539- - 6 ~ c~ y <br />If you have additional eommcrtts 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 aze enclosed. <br />Signature of Corporate Officer, O , or Designee <br />lc'IYI~~S <br />