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tPITTEENAME <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />te/-s <br />-# I' /" f-- <br />ANNU EE `and REPOZT REQUEST <br />I Lafarge West, Inc. 10 <br />-1977-439 i,60 <br />Home Office Mine <br />®0 <br />August 15, 2010 4 <br />$$791.00 (Due on or before your anniversary date) <br />Larimer <br /> <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, 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 vear's man are necessarv. then no new man 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 O. Ray <br />Permittee Name: Lafarge West, Inc. <br />Address: 10170 Church Ranch Way, Ste. 200 <br />Westminister, CO 80021 <br />Phone Number: (303) 657-4579 <br />Fax Number: (303) 657-4037 <br />If you have additional comments and/or information that should be <br />below or attach ' his form along with your written report and map. <br />Signs ure of Corporat Offic r, Owner, or Designee <br />Date <br />provided to the Division, please provide it <br />Annual Report instructions are enclosed.