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<br />~~ _ ~ ~~ <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />ak Stone &Aggr Supply, Iuc. <br />1981-080 <br />Tezak No 2 Pit <br />May 27, 2007 ice`/"!/ <br />~ ~ ~1, <br />$$0.00 (Due on or before your anniversary date) <br />Fremont <br /> <br />,., , %~~~ <br />D;eri~.. ,. ~ ten' <br />y <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-1 l6, each yeaz, 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 yeaz, 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. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, resort, and associated <br />man. If no new disturbances or reclamation have occurred durinti the previous year and no new chanties to <br />the previous year's map are necessary, then no new man is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permi[tee Contact: Mike A. Tezak <br />Permittee Name: Tezak Stone &Aggr Supply, Inc. <br />Address: 6200 CR 37 <br />Texas Creek, CO 81223 <br />Phone Number: (719) 275-1146 <br />Fax Number: (719) 275-1146 <br />~vt,,V~>l7~wy ~S Go~Atcf <br />-~ <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 />~~ L^l `~ <br />Signature of Corporate Officer, Owner, or ignee <br />Date <br />