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~o -i~ -off <br /> ~tvir <br />RECEI~ <br /> ~ <br />ED <br />PERMITTEE NAME: The Denver Brick Company dba Acme Brick CompanyDivisio <br />ns <br />PERMIT NO.: '~ M-1976-007-UG q of <br />n'lyring aRd Sa eation <br /> , <br />IY <br />OPERATION NAME: Golden Mine <br />ANNIVERSARY DATE: October 4, 2006 <br />ANNUAL FEE DUE: $281.00 (Due on or before your anniversary date) <br />COUNTY: Jefferson <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 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-tGpcoming~€ar,-reclamation thaHvil]-be-performed during-the-comingycai; the-ddte~f6r'[1'ie beginning <br />of active operations, and the date active operations ceased for the yeaz, if any. <br />Please attach vour revised written annual report and annual report map to this form. The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, repprt, and associated <br />map. If no new disturbances or reclamation have occurred during the previous vear and no new chanties to <br />the previous year's map are necessary, then no new map is required, provided that the Operator shall state <br />this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the <br />above elements may since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: <br />Permittee Name: <br />Address: <br />Albert Templeton <br />The Denver Brick Company dba Acme Brick Company <br />401 Prairie Hawk Dr. <br />Castle Rock, CO 80109 <br />Phone Number: (303) 688-6951 <br />Fax Number: (303) 688-9894 <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 aze enclosed. <br />Signature of Co/rlporate ficer, Owner, or Designee <br />/~/ ~a <br />Date <br />