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<br />J[ Z o% <br />ANN 4AFEE and RE RT REOUEST <br />PERMITTEE NAME: ?-The Denver Brick Company dba Acme Brick Company RECEIVED <br />PERMIT NO.: ?-1976-007-UG ;' s,r--P 3 D 2010 <br />OPERATION NAME: Golden Mine Vivisio') Ut <br />'ling 'n <br />ANNIVERSARY DATE: October 4, 2010 ?d'y <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: Jefferson <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 man 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 chances 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; ? <br />20" 1 i" <br />Permittee Name: The Denver Brick Company dba Acme Brick Company <br />Address: <br />Cis-FIB fat jc.. D SG/?i. g <br />Phone Number: <br />Fax Number: <br /> <br />y_r(/lj?lkj ?t•1?C <br />X03- ??Sf <br />303-/ 47- 929Y <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 />R Z A010 <br />Date