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III Illllllllllll Ill <br /> ANNUAL FEE and REPORT REOUEST RECEIVED <br /> BCD <br /> PERMITTEE NAME: Mobile Premix Concrete,Inc. AU, 3 1209, <br /> PERMIT NO.: M-2000-002 Oivisinn Of minerals and Geology <br /> OPERATION NAME: Tanabe Pit <br /> ANNIVERSARY DATE: September 22,2001 <br /> ANNUAL FEE DUE: $688.00(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 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 year, reclamation that will be performed during the coming year, the dates for the beginning <br /> 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 clearly delineates and includes the 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: John Hickman <br /> Permittee Name: Mobile Premix Concrete, Inc. <br /> Address: 1590 W.12th Ave. <br /> Denver,CO 90204 <br /> Phone Number: (303) 657-4330 <br /> Fax Number: (303)657-4339 <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 /> X 13 A 1'k fji.w. . 1,4( L. R <br /> ` Si nature of Corporate lcer or Owner <br /> Uv &!'/D/ <br /> Date T <br /> MIPERMITMASTERDOCUMENTSW AF-01 <br />