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~p~n~nu,a9.. ~-~`~ <br />ANNUAL FEE and REPORTJREQUEST <br />PERMITTEE NAME: Colorado Marble, Inc. `~ <br />PERMIT NO.: M-1987-028 <br />OPERATION NAME: Lily Mines <br />ANNNERSARY DATE: March 18, 2009 <br />ANNUAL FEE DLTE: $791.00 (Due on or before your anniversary date) <br />COiJNTY: Chaffee <br /> <br />~ AP(~ li ~ 2009 <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 wing fhe 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 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 during the previous year and no new changes 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 since 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 />~ ~ ~~,~ Ste, ~ow~sk; <br />Permittee Name: Colorado Marble, Inc. _~( u . ks e f e (~ w-f P c ~ a ls, L- L ~- <br />Address: 229 Industrial Park Rd NE ~tI 4 a 'P : e ~ M.on7 R ~ . , S~° ~ 3 u e <br />_~ ~ Cartersville, GA 30121 ~ A t 1. a r~-E r1. ~~'~ A ~ ~ a~ ~ .S <br />Phone Number: (770) 607-3345 ~d ~( ~ 3 ~( 9 1 U 6 <br />Fax Number: (770) 607-3346 ~iZ 7~ ~ l 7 ~ ? Q 6 <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 Corporate ficer, Owner, or Designee <br />3~Z ~~~ ~ <br />Date <br />