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ec S n/" <br /> <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEES and REPORT RE UEST <br />c? halt Specialties Co., Inc. <br />77M-2004-009 <br />Turnpike Mining Resource <br />August 4, 2010 <br />vAUG 022010 <br />p ion nr Reck W, <br />Wining and 3a f <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Weld <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, re-c-Famation that will be -performed during the coming year, th-e 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 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: Rob Laird <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 />O? <br />Date/'