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<br />PERMITTEE NAME: \ _Summit Brick & Tile Co. <br />PERMIT NO.: / <br />?(d M-1977-317 <br />rf <br />AN AL FEE and 6PORT REQUEST <br />?Ao <br /> <br />OPERATION NAME: Cedarwood Clay Mine <br />ANNIVERSARY DATE: December 15, 2010 <br />ANNUAL FEE DUE: $$323.00 (Due on or before your anniversary date) <br />COUNTY: <br />Pueblo <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 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 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: Joseph C. Welte <br />Permittee Name: Summit Brick & Tile Co. <br />Address: P.O. Box 533 <br />Pueblo, CO 81002-0533 <br />Phone Number: (719) 542-8278 <br />Fax Number: (719) 542-5243 <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 />Sign re of Corporate Officer, Owne , or Designee <br />Z Zo('D <br />Date