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ANNJIFEE end REPORT REQUEST <br />PERMITTEE NAME: Agummit Brick & Tile Co. R`ECENE® <br />PERMIT NO.: VA-1977-322 ,06 19 200 <br />OPERATION NAME: Beaver Crk Clay Mine Division of Reclamation, <br />ANNIVERSARY DATE: February 17, 2009 Mining and Safety <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Fremont <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-corning. 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. 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 during the previous year and no new changes to <br />the previous year's may are_necessarv, then no new map is reauired, Drovided 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: Joseph C. Welte <br />Permittee Name: Summit Brick & Tile Co. <br />Address: P.O. Box 533 <br />Pueblo, CO 81002-0533 <br />Phone Number: (719) 542-8278 <br />Fax Number: (719) 542-5243 <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 />^ n <br />Signatu of orporate Officer, Owner, or esignee <br />,2- 17 /;7_00 <br />Date