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V ~" <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />Mobile Premix Concrete, Inc. <br />M-2000-002 <br />Tanabe Pit <br />September 22, 2002 <br />$688.00 (Due on or before your anniversary date) <br />Adams <br />RECEIVED <br />ocr ~ s zoo2 <br />Division of Minerals and Geology <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 />- --shaA-submit-the-annuaLfee,_a report_and_map~howing the extent of current disturbances to affected land, _ <br />reclamation accomplished to date and during the preceding year, new disturbances that are anticipated [o 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 />adegaately 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 /> <br />Permittee Contact: Jo an <br />Permittee Name: MohilP vrP.,.. rzs. - ~• <br />Address: 1590 W.12th Ave. <br /> Denver, CO 80204 <br /> r /- <br />~~3 W <br />Phone Number: (303) 657-43 <br />Fax Number: _ (303) 657-4339 <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 />Dat~ <br />M 1PERM ITIMASTERD(KUMENTSVv1-AF-01 <br />