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<br /> ANNUAL FEE and REPORT REQUEST <br /> <br />PERMITTEE NAME: ?/T/ ezak Stone & Aggr Supply Inc <br />PERMIT NO.: M-1981-080 <br />OPERATION NAME: Tezak No 2 Pit <br />ANNIVERSARY DATE: May 27, 2009 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Fremont <br />0A <br />w9GOVED <br />AM AY 2 8 2UO1 <br />Divisive of I ecrm&ti0n, <br />7tv minkv and Safety <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 ye ar,-reclamation that will be performedduring the coming year, the dates ohe begnning <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 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 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: Mike A. Tezak <br />Perm ittee Name: Tezak Stone & Aggr Supply Inc <br />Address: 6200 CR 37 <br />Texas Creek, CO' 81223 <br />Al? -is c - oA <br />Phone Number: (719) 275-1146 <br />Fax Number: (719) 275-1146 <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 />0?? 0" R." <br />Signature of Corporate Of ricer, Owner, or esignee <br />M a'? '?)-4 , a- () 0 ? <br />Date