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i <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />1 4�,c , V Rt" <br />ANNUA L FEE and REPORT REQUEST <br />Summit Brick & Tile Co. <br />l I �I- 1977 -317 <br />Cedarwood Clay Mine <br />December 15, 2009 <br />/DEC REC 15 2009 <br />Division o Reclamation, <br />Mini g nd Safe <br />$$323.00 (Due on or before your anniversary date) <br />Pueblo <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 pr- eceding year ne w_ disturbances_that are.anticipatq 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 th 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 n o new chanties to <br />the previous year's map are necessary, then no new map is required, provided that the O perator 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: Joseph C. Welte <br />Permittee Name: Summit Brick & Tile Co. <br />Address: P.O. Box 533 <br />pueblo,-CO 81002 -0533 <br />Phone Number: (719) 542 -8278 <br />Fax Number: (719) 542 -5243 <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 />Sig re 6f Corporate Officer, Owne , or Designee <br />1 ?-oo <br />Date <br />