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/f ~ = r~°~ <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNIIAT, FF.F, and RF.PnRT RF.OTTFIST <br />A/d~ms County <br />l/M-1977-283 <br />Debetz Pit <br />December 21, 2005 <br />RECEIl~EI` <br />UCC U I GuOJ <br />Oieision of Minerals ai~~ ..: " <br />$688.00 (Due on or before your anniversary date) <br />Adams <br />~~~ <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 thy-erutttal-fee; a-report-and-map,showing-the-extent of.eurrenGdishlrbances.tr,_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, 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 anmral rennrt and anmral report maT to this form- Please note that an <br />adequately labeled map that clearly delineates and includes the above elements may since 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: <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Craig Tessmer <br />Adams County <br />4955 E. 74th Ave. <br />Commerce City, CO 80022 <br />(303) 853-7003 <br />(303)853-7015 <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 />/~ <br />Si ture of C ate Officer, Owner, or Designee <br />av~ct.g~ l ~, Z~S <br />Date <br />M:~PERMITN7ASTERDOCUMENTS~M-AF-09 <br />