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t • .. III 999 III <br /> ANNUAL FEE and REPORT REQUEST <br /> PERMTITEE NAME: Hard Rock Paving & Redi-Mix, Inc. R C <br /> PERMIT NO.: M-1984-101 <br /> OPERATION NAME: Chaparral Meadows Pit <br /> ANNIVERSARY DATE: August 13,2001 of Vtsta°OfMi , <br /> ANNUAL FEE DUE: $688.00(Due on or before your anniversary date) erals0ndGa%py <br /> COUNTY: Park <br /> According to C.R.S. 34-32.5-1 16 or C.R.S. 34-32-116,each year, on the anniversary date of a permit, an operator <br /> shall submit the annual fee, a report and map showing the extent of current disturbs ces to affected land, <br /> reclamation accomplished to date and during the preceding year, new disturbances that ar 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 map that clearly delineates and includes the above elements may sufficej ir a written report. <br /> Division records indicate the following permittee contact information. Please verify anc make any necessary <br /> changes: <br /> Permittee Contact: Angela Bellantoni <br /> Permittee Name: Hard Rock Paving & Redi-Mix, Inc. <br /> Address: P.O. Box 1720 <br /> Canon City, CO 81215-1720 <br /> Phone Number: (719) 275-1280 <br /> Fax Number: (719) 275-8897 <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/� � 1 4 <br /> Signatul of Corporate Offi er or Owner <br /> { u.f a 13 scot <br /> Date <br /> M\PERMITMASTERDOCUNIENTSNI-AF-01 <br />