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.-, . <br />ANNUAL FEE and REPORT REQUEST <br />cK~35y(p~~(o8K~=4 <br />RECEIVED <br />PERMITTEE NAME: Mathias Concrete, Inc. <br />PERMIT NO.: M-1977-140 <br />OPERATION NAME: N Farm Rd Pit No 1 <br />ANNIVERSARY DATE: January 15, 2001 <br />JAN 1 1 2001 <br />Division of Ninerals end Geology <br />ANNUAL FEE DUE: $688.00 (Due on or before your anniversary date) <br />COUNTY: Rio Grande <br />According to C.R.S. 34-32.5-116 or C.R.S. 34-32-116, each year, on [he anniversary date of the permit, an <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, [he dates for the <br />beginning of active operations, and [he date active operations ceased for [he year, if any. <br />Please attach your revised written annual report and annual report man to this form. Please rote that an <br />adequately labeled map that clearly delrnentes and includes the rebore elements nrcry suffice jot u wri[tee <br />report. <br />Division records indicate the following pennittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact. Thomas G. Mathias <br />Permittee Name: Mathias Concrete, Inc. <br />Address: 1500 N. Fawn Rd. <br />P.O. Box 266 <br />Phone Number: <br />Fax Number: <br />Monte Vista, CO 81144 <br />(719)852-3732 <br />(719) 852-3759 <br />If you have additional comments and/or information that should be provided [o the Division, please provide it <br />below or attach it to this form along with your written report and map. Annual Report instructions are <br />enclosed. <br />Signatur of Corpor e fficer or Owner <br />-~~~, ~ <br />Date <br />ERMITUMSTE RDOC UMEMSV.1-AF-01 <br />