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N~ <br />ASS <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Harold Brandstadt <br />M-1986-004 <br />Brandstadt Rock Pit <br />Tanuary 24, 2005 <br />$281.00 (Due on or before your anniversary date) <br />Delta <br />EAU ~ o ~~~~ <br />Diviaivu ai i:. L:.:r :, -. ?wlo; g <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 />_ ___shallsubmit- the_amiual_ fee, ,a_reportand~nap~ow~ng_ the~xtent o~cuxrentdistiv]~anoes_to_affeated 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 year, the dates for the beginning <br />of active operations, and the date active operations ceased for the year, if any. <br />Please attach XDnr revised written annual re~yt and annual repprf main, to this fnrm_ 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 following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact Harold Brandsstadt <br />Permittee Name: Harold Brandstadt <br />Address: 2040 G Rd. <br />Delta, CO 81416 <br />Phone Number: (970) 874-4159 <br />Fax Number: - - <br />~oil~6 G rid, <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 />Signature of Corporate Officer, Owner, or Designee <br />0200 <br />Date <br /> <br />