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~. <br />Adams County <br />M-1977-283 <br />Debetz Pit <br />December 21, 2003 <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br /> <br />nEC z z zoo3 <br />Division of Minerals and Geology <br />$688.00 (Due on or before your anniversary date) <br />Adams <br />_ According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on the <br />operator shall submit the annual fee, a_report-and=map-showing-the extefr <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach ymlr revised written annnal re~nrt and annual rennrt m ~n to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since for a written <br />report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: Craig Tessmer <br />Permittee Name: Adams County <br />Address: <br />phone-AFumber: <br />Fax Number: <br />4955 E. 74th Ave. <br />Commerce City, CO 80022 <br />(303)853-7015 <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 <br />enclosed. <br />Signature of Corporate Officer, Owner, or Designee <br />Date <br /> <br />M:\PERMIT\MASTERDOCUM ENTSVv1-AF-04 <br />