2005-12-13_REPORT - M1984099

• Permit No: M1984099
• IBM Index Class Name: Report
• Doc Date: 12/13/2005
• Doc Name: Annual Fee/Report/Map
• From: Goose Haven Sand & Gravel Inc.
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY;

ANNIJAi. FF.F, and RF.PnRT RF.nIJF.ST
i
Goose Haven Sand & Gravel, Inc. ~, , , ,
M-1984-099 ~ .% 2G.:J
Bailey Pit - - '
September 29, 2005
$688.00 (Due on or before your anniversary date)
Weld
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
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 ym~r revised written annual rennrt and annual re~nrt masn, 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: Doug Tiefel
Permittee Name: Goose Haven Sand & Gravel, Inc.
Address: P.O. Box 17130
Boulder, CO 80308
Prone-Number.:-.(3D3}665-9390
Fax Number: [phone]
~o C~anet>Z
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, Owner, or Designee
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Date