2004-10-15_REPORT - M1980205

• Permit No: M1980205
• IBM Index Class Name: REPORT
• Doc Date: 10/15/2004
• Doc Name: Annual Fee/Report/Map
• From: Select Materials
• To: DMG
• Permit Index Doc Type: Annual Fee / Report
• Media Type: D
• Archive: No

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Select Materials
M-1980-205
Select Materials
October 2, 2004
REC~9F~~®
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
~A~/
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OCT 15 2004
Dirisiao of &Siac.afs 8 Geology
$688.00 (Due ou or before your anniversary date)
Weld
According to C.R.S. 34-32.5-116 or C.R.S. 34-32-I 16, each year, on the anniversary date of the permit, an operator
shall submit the annual fee, a report and map showing the extent of current disturbances to affected land,
reclamation accomplished=fo_date.and_during the preceding year; new disturbances that are anticipated to occur -
during the upcoming year, reclamation that will be performed during the comingyear-the•dates_foLthe~eginning
of active operations, and the date active operations ceased for the year, if any.
Please attach ym~r revived written annual rennrt and annual re n~ rt may to this form- Please note that an
adequately labeled map that clearly delineates and includes the above elements may since for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Robert D. Oman
Permittee Name:
Address:
Select Materials
P.O. Box 280
Fort Lupton, CO 80621
Phone Number: [phone]
Fax Number: [phone]
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are enclosed.
/Gti~i
ignature of Co orate Officer, Owner, or Designee
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