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d6-Z- <br />ECEIVE <br />< % NOV 0 4 7009 <br />ANNUAL FEE and E ORT REQUEST <br />BY: <br />PERMITTEE NAME: `The Denver Brick Company <br />PERMIT NO.: 1i1v1- 1996 -064 <br />OPERATION NAME: Stevens Clay Lease <br />ANNIVERSARY DATE: December 23, 2009 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Douglas <br />nK <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 accomplish - to - date and-duritig the - 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 vour 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 vear's map are necessary, then n o new may 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: A4be r+er� <br />Permittee Name: The Denver Brick Company <br />Address: 401 Prairie Hawk Dr. <br />Castle Rock, CO 4884-94 80 109 <br />Phone Number: (303) 688 -6951 <br />Fax Number: (303) 688 -5270 <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 />'20 <br />Date �EC <br />Date �' <br />