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CK V-1 .591 1 `I 68k <br /> � ` � IIIIIIIIIIIIIIIIIII � <br /> 999 <br /> ANNUAL FEE and REPORT REQUEST <br /> RECEIVED <br /> PERMITTEE NAME: Asphalt Specialties Co., Inc. 2 Z� <br /> PERMIT NO.: M-1983-176i NOV <br /> OPERATION NAME: Speer Mining Resource piriston <br /> of Minerals and Goolo9Y <br /> ANNIVERSARY DATE: December 9,2000 <br /> ANNUAL FEE DUE: 5688.00 (Due on or before your anniversary date) <br /> COUNTY: Adams <br /> 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 <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 perfonned during the coming year, the dates for the <br /> beginning of active operations, and the date active operations ceased for the year, if any. <br /> Please attach your revised written annual report and annual report map to this form. Please note that an <br /> adequately labeled map that clear!, delineates and includes the above elements may suffice for a written <br /> report. <br /> Division records indicate the following permittee contact information. Please verify and make any necessary <br /> changes: <br /> Permittee Contact: 4:0 Steen ha a 5R <br /> Permittee Name: Asphalt Specialties Co., Inc. <br /> Address: 7321 E 88th Ave. Ste. 100 <br /> Henderson, CO 80640 <br /> Phone Number: (303) 289-8555 <br /> Pax Number: CIA f Z 89 - IF67 <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 <br /> enclosed. <br /> Signature of Corporate Officer or Owner <br /> Illizoloo <br /> Date <br /> M TERMIPMASTERDOCUMENTSW-AF-0I <br />