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V9 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />Af ' q1- <br />ANNUAL FEE and REPORT REOUEST <br />?f Tezak Heavy Equipment Co. Inc. <br />dM-1977-193 <br />T.H.E. Aggregate Source <br />November 22, 2009 <br />OCT 2 6. 009 <br />DM+tWn of Redwadw, <br />c fD Moming and Wety <br />$$791.00 (Due on or before your anniversary date) <br />Fremont <br />V <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 lie performed - urmg he 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: Daniel Tezak <br />Perm ittee Name: Tezak Heavy Equipment Co. Inc. <br />Address: 205 Tunnel Dr. <br />Canon City, CO 81212-3660 <br />Phone Number: (719) 269-1173 <br />Fax Number: (719) 269-1148 <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 />Signat e of Corporate Officer, Owner, or Designee <br />U /a3 /a o d 2? <br /> <br />Date