_REPORT - M1977140 ‎(2)‎

• Permit No: M1977140
• IBM Index Class Name: Report
• Permit Index Doc Type: ANNUAL FEE / REPORT
• Media Type: D
• Archive: No

999
ANNUAL FEE and REPORT REOUEST RECEIVED
PERMITTEE NAME: Mathias Concrete, Inc. RECEIVE®
PERMIT NO.: M-1977-140 JAN 14 2002
OPERATION NAME: N Farm Rd Pit No 1
Division of Minerals and Geology
ANNIVERSARY DATE: January 15,2002
ANNUAL FEE DUE: $688.00(Due on or before your anniversary date)
COUNTY: Rio Grande
According to C.R.S. 34-32.5-116 or C.R.S. 34-32-1 16, 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 suffice for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Thomas G.Mathias �7
Permittee Name: Mathias Concrete, Inc. >°y
Address: 1500 N. Fa,�'n Rd.
P.O. Box 266 V 5
Monte Vista,CO 81144 y eS
Phone Number: [phone] u ��
Fax Number: [phone]
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.
Signature of Corporate Office or Owner
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