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065 <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />A (� A r <br />AE and P RT REQUEST <br />NP 'llips Stone Company <br />"M -1981 -075 <br />Phillips Stone Company <br />July 30, 2010 <br />$$323.00 (Due on or before your anniversary date) <br />Boulder <br />d//- <br />RECEIVEI) <br />Al 2 7�9j9 <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- dur -ing- the - preceding year,- new. disturbances _that - are -anticjpated 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 J. Phillips <br />Permittee Name: Phillips S one Company IV <br />Address: 7850 Ute Hwy <br />Longmont, CO 80503 <br />Phone Number: (303) 823 -6395 <br />Fax Number: (303) 485 -2706 <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 esignee <br />Dat <br />