_REPORT - M1980205

• Permit No: M1980205
• IBM Index Class Name: Report
• Doc Name: Annual Fee/Report Notice
• Permit Index Doc Type: ANNUAL FEE / REPORT
• Media Type: D
• Archive: No

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ANNUAL FEE and REPORT REQUEST
PERMITTEE NAME: Select Materials
PERMIT NO.: M-1980-205
OPERATION NAME: Select Materials glvlslonolMlne'`
ANNIVERSARY DATE: October 2,2001
ANNUAL FEE DUE: $688.00(Due on or before your anniversary date)
COUNTY: Weld
According to C.R.S. 34-32.5-1 16 or C.R.S. 34-32-116, each year, on the anniversary date of the permit, an operator
shall submit the annual fee, a report and map showing the extent of current disturbances to affected land,
reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur
during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning
of active operations, and the date active operations ceased for the year, if any.
Please attach your revised written annual report and annual report map to this form. Please note that an
adequately labeled map that clearly delineates and includes the above elements may since for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Robert D. Oman
Permittee Name: Select Materials
Address: P. O. Box 280
Fort Lupton, CO 80621
Phone Number: [phone]
Fax Number: :303 — &3 7 — 7 3 3 /
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are enclosed.
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Signature of Corporate Officer or Owner
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Date
M'1PERMrM1ASTERDOCUMENTSVN-AF-01