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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Asphalt Specialties Co., Inc. <br />M-1983-176 <br />Speer Mining Resource <br />December 9, 2004 <br />$688.00 (Due on or before your anniversary date) <br />Adams <br />RECEIVE® <br />DEC 0 8 2~"1 <br />Oivisian ~f Minerals and Saology <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-fo`date and~duririg-the'precedingryear,-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 anm~al repnH and anm~al rennrt map to this form- P(eaSe 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: -~-=-',~a.~-"',.-'~~ Rob ~-q-P2~ <br />Permittee Name: Asphalt Specialties Co., Inc. /~~11 <br />Address: '~~~ ~ R '- "--,"..,...,.,- 1100 1~alle.5 7c-• <br />~le->cler~xn, Co ~~io <br />Henderson, CO 80640 <br />Phone Number: (303) 289-8555 <br />Fax Number: (303) 289-7707 <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 />~~~/~~ <br />Signature of Corporate Officer, Owner, or Designee <br />/Z-~--Og <br />Date <br />