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ANNiiAi. FF.F. and RF.PIIRT RF.niTF.ST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Holcim (US) Inc. <br />M-1977-348 <br />Boettcher Limestone Quarry <br />October 10, 2004 <br />$688.00 (Due on or before your anniversary date) <br />Larimer <br /> <br />~~~- <br />oC% - <br />OipRtio l S~0 <br />nor _ ~~ <br />r,., <br />qP°t0ar <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 />rcdan;aGo,~ acc~,~tvli~hed tG daie and during the preceding year, new disturbances that are anticipated to occur <br />duri:~o th. upcoming y.°ar, rfoiaena~ion ghat will be performed during the coming year, fne dates fur thr beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach vnur revised written annnal rennrt and annnal r~nrt maTtn this form- 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 fallowing permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Gordon Benton <br />Permittee Name: Holcim (US) Inc. <br />Address: Project Manager <br />P.O. Box 1548 <br />La Porte, CO 80535 <br />Phone Number: (970) 482-4065 <br />Fax Number: (970) 482-1363 <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 />Sigitature of Corporate Officer, Owner, or Designee <br />Date <br />