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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />Lafarge West, Inc. <br />R~c~~~ED <br />M-1991-035 - DEC ~ 9 ZQQj' <br />Div~inin ~~ kec~a n <br />Bluestone Pit 9 and ma[io <br />SafeiY <br />November 5, 2007 <br />$$791.00 (Due on or before your anniversary date) <br />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 _ann_ual 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 man to this form The Annual Report <br />& Fee requirement is not met until we have received the following components: fee, report, and associated <br />map. If no new disturbances or reclamation have occurred durin the revious ear and no new chap es 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 suffice 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 />Robert O. Ray <br />Lafarge West, Inc. <br />Address: 10170 Church Ranch Way, Ste. 200 <br />Westminster, CO 80021 <br />Phone Number: (303) 657-4579 <br />Fax Number: (303) 657-4037 <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 />Signature of Corpora e Offic ,Owner, or Designee <br />i~~~ 07 <br />Date <br />