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ANNUAL FEE and REPORT REQUEST <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Mathias Concrete Inc <br />M-1977-140 <br />N Farm Rd Pit No 1 <br />January 15, 2011 <br />$791.00 (Due on or before your anniversary date) <br />Rio Grande <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 aCCGlmlpliSieu to date and during the preceding year, ile'JJ disturbanCeS that are ailtlCipated 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 reauired, 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: Thomas G. Mathias <br />Permittee Name: Mathias Concrete Inc <br />Address: 1500 N. Farm Rd. <br />P.O. Box 266 <br />Monte Vista, CO 81144 <br />Phone Number: (719) 852-3732 <br />Fax Number: (719) 852-3759 <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 />Date