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iii iiiiuiiiiiu iii ~ <br />999 <br />ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: Asphalt Specialties Co., Inc. RECEI VEp <br />PERMIT NO.: M-1983-176 JAN 0 41001 <br />OPERATION NAME: Speer Mining Resource <br />Division of Minerals and Geology <br />ANNIVERSARY DATE: December 9, 2001 <br />ANNUAL FEE DUE: $688.00 {Due on or before your anniversary date) <br />COUNTY: Adams <br />According [o C.R.S. 34-32.5-116 or C.R.S. 34-32-1 16, 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 vour revised written annual report and annual report map to this form. please note that n[I <br />adequately labeled map [ha[ clearly delineates aitd includes the above elements ma~~ since for a written report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permi[tee Contact: ~Finr9vHrvmr'}?pb ~a ird <br />Permi[tee Name: Asphalt Specialties Co., Inc. <br />Address: 7321E 88th Ave. Ste. 100 <br />Henderson, CO 80640 <br />07 9vy-agp5- <br />Phone Number: (303) 289-8555 <br />Fax Number: (3p~j~ ~-7'7~7 <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 />y V~ <br />Signature of Corporate Officer or Owner <br />~-a- ~-- <br />Date <br />AI 7PERM rIV.1ASTERDOCDAfENTSNI-AF~01 <br />