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<br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />t/ <br />ANNUAL FEE and REPORT REQUEST <br />RECEIVED <br />Asphalt Specialties Co., Inc. <br />M-1983-176 <br />Speer Mining Resource <br />December 9, 2002 <br />DEC 0 ~ 2002 <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 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 ducmg [he preceding year, new disturbances that aie anticipated "fo occur <br />during the upcoming year, reclamation [hat 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 resort and annual reuort mau to this form. Please note that an <br />adequately labeled map that clearly delineates mul 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: ~n~n~iiiii~ixR- <br />Permittee Name: Asphalt Specialties Co., Inc. <br />+~ob Lta,i rC~ <br />Address: 7321E 88th Ave. Ste. 100 <br />Henderson, CO 80640 <br />Phone Number: (303) 289-8555 <br />Fax Number: <br />(~'3~ 2~f -~7~67 <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 />~rJ <br />Signature of Corporate Officer, Owner, or Designee <br />Z- lo- t~Z <br />Date <br />M iPERM771MASTERDOC UM ENTSVN-AF-01 <br />