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PERMITTEE NAME: <br />PERMIT NO.: <br />I OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REOUEST <br />P A phalt Specialties Co., Inc. <br />21983 -176 <br />Speer Mining Resource <br />December 9, 2009 <br />RECO Y E-D <br />/DEC 0 7 Z009 <br />Division of Reclamation, <br />h Mining and Safety <br />$$791.00 (Due on or before your anniversary date) <br />Adams <br />Olt <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 distu th a re ant icipated 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 />i <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: stint 1 2 -,o6 "ird <br />Permittee Name: Asphalt Specialties Co., Inc. <br />Address: 10100 Dallas St. <br />Henderson, CO 80640 <br />Phone Number: (303) 289 -8555 <br />Fax Number: (303) 289 -7707 <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 />i2- 04 —Zpo <br />Date <br />