REP00021 ‎(2)‎

PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
Robinson Brick Company
M- 1978 -014
North Chieftain
August 14, 2005
JUL 13 2005
Division of Minerals & Geology
$688.00 (Due on or before your anniversary date)
Jefferson
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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
shall- submit - the - annual- fee, -a- report-and- map - showing- the - extent -of- current- disturbances- to- affected-land, --
reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur
during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning
of active operations, and the date active operations ceased for the year, if any.
Please attach your revised written annual report and annual report map to this foamy 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: Michael C r cidich
Permittee Name: Robinson Brick Company
Address: 1845 W. Dartmouth Ave.
Englewood, CO 80110 -000
Phone Number: 4.304483 -304 3- 3- .3cy'b
Fax Number: 043)- 1 ' ° 7 4 3 -
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.
ature of Corporate 07041wor Designee
X161
Date