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r <br />T <br />rPfRT AE and REQUEST <br />OCT 0 2 2009 <br />PERMITTEE NAME: he Denver Brick Company dba Acme Brick Company <br />z vision of Reclamation, <br />PERMIT NO.: I-1976-007-UG Mining and Safety <br />OPERATION NAME: Golden Mine <br />ANNIVERSARY DATE: October 4, 2009 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: 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 annual fee, a report and map showing the extent of current disturbances to affected land, <br />reclamation accomplished to date- and dudngthe_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 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: Robert Tibbetts <br />Permittee Name: The Denver Brick Company dba Acme Brick Company <br />Address: 401 Prairie Hawk Dr. <br />Phone Number: <br />Fax Number: <br />Castle Rock, CO 80109 <br />(303) 688-6951 <br />(303) 688-9894 <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 Officer, Owner, or Designee <br />Date