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~17~ ~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNNERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />4~ <br />ANNTJAT. FF.F, and RF.P(1RT RF.OTIF.ST - <br />~F 'k'/'I <br />. H/olcim (US) Inc. ~h <br />t~M-1977-347 <br />Slab Canyon Quarry <br />October 10, 2005 <br />''seP 2 ~ 2005 <br />/ V OIYISICL G . '.::.le [P <br />$685.00 (Due on or before your anniversary date) <br />Lorimer <br />According to C.R.S, 34-32.5-116 or C.R.S. 34-32-116, each yeaz, 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 during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming yeaz, reclamation that will be performed during the coming yeaz, the dates for the beginning <br />of active operations, and the date active operations ceased for the yeaz, if any. <br />Please attach your revised written annual re~nrnrt and anmial re;~t ma= to this form. Please note Lhat an <br />adequately 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 />Permittee Contact: Gordon Benton <br />Permittee Name: Holcim ([JS) Inc. <br />Address: Project Manager <br />P.O. Box 1548 <br />La Porte, CO 80535 <br />Phone Number: (970) 482-4065 <br />Fax Number: (970) 482-1363 <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 />/~-- <br />Signature of Corporate Officer, Owner, or Designee <br />,~ 26 "~ <br />Date <br />