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<br />ff?AFE?Eand REPORT RE UEST <br />PERMITTEE NAME: ?Holcim (US) Inc. <br />PERMIT NO.: 'I'M-1977-346 <br />OPERATION NAME: Boettcher Gypsum Quarry <br />ANNIVERSARY DATE: October 10, 2010 <br />ANNUAL FEE DUE: $$791.00 (Due on or before your anniversary date) <br />COUNTY: Larimer <br /> <br /> -7 <br /> <br />?? •, <br />.. ? ..J 1 <br />. is <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_accomptished_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 year's map are necessary, then no 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: Michael B. Toelle <br />Permittee Name: Holcim (US) Inc. <br />Address: 3500 Highway 120 <br />Florence, CO 81226 <br />Phone Number: (719) 784-1402 <br />Fax Nur4ber: (719) 784-3470 <br />If You AAe tional comments and/or information that should be provided to the Division, please provide it <br />below a to this form along with your written report and map. Annual Report instructions are enclosed. <br />Signature?of Corporate Officer, Owner, or Designee <br />Date <br />p