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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />• i1%1 ~-- <br />v ANNiiAi. FF.F. and REPORT RF,OTTFST <br />/~ Robinson Brick Company <br />M-1977-251 <br />Lariat Pit <br />March 5, 2006 <br />~G~~I V ~® <br />~P~AR 1 ~ Z006 <br />~mision Hof Minerals end Goolo6Y <br />$688.00 (Due on or before your anniversary date) <br />Jefferson <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an operator <br />shall submit the annual fee, a report and map showing the extent of current disturbance$ to affected land, <br />-reclamation-accomplished-to-date-and-during-the-precedingyear,-new-disturbances'that aee'atiticipated-to occur- - - <br />during the upcoming year, reclamation that will be performed during the coming year, the dates for [he beginning <br />of active operations, and the date active operations ceased for the year, if any. i <br />Please attach ymn• revised written annual re~nrt and anm~al report mom} to this form- P, lease note that an <br />adequately labeled map that clearly delineates and includes the above elements may suffice for k written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Marvin R. Myers, Jr. <br />Permittee Name: Robinson Brick Company <br />Address: 1845 W. Dartmouth Ave. <br />Denver, CO 80110-1308 <br />Phone Number: (303) 783-3046 <br />Fax Number: (303) 783-2992 <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 fonn along with your written report and map. Annual Report instructions are enclosed. <br />Signature of Corporate Officer, Owner, or Designee <br />Date <br />