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99 <br /> R <br /> ANNUAL FEE and REPORT REOUEST <br /> PERMITTEE NAME: The Denver Brick Company Division Df Miner sand Sealant' <br /> PERMIT NO.: M-1976.007-UG <br /> OPERATION NAME: Golden Mine <br /> ANNIVERSARY DATE: October 4,2001 <br /> ANNUAL FEE DUE: $281.00(Due on or before your anniversary date) <br /> COUNTY: 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 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 report and annual report map to this form. Please note that an <br /> adequately labeled nzap that clearly delineates and includes the above elements may suffice fora written report. <br /> Division records indicate the following permittee contact information. Please verify and make any necessary <br /> changes: / <br /> Permittee Contact: 1�eynezSpe»ee �J (i,l eS <br /> Permittee Name: The Denver Brick Company <br /> Address: 401 Prairie Hawk Dr. <br /> Castle Rock, CO 80104 <br /> Phone Number: (303) 688-6951 <br /> Fax Number: (303) 688-5270 <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 /> r � <br /> lgnatur f Corporate Officer or Owner <br /> /tq -3 -01 <br /> Date <br /> M:W ER WRMASTERDOCUMENTSW-AF-01 <br />