2011-01-12_REPORT - M1977140

• Permit No: M1977140
• IBM Index Class Name: REPORT
• Doc Date: 1/12/2011
• Doc Name: Annual Fee/Report/Map
• From: Mathias Concrete Inc
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Media Type: D
• Archive: No

NI;7 it RP'T
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
ANNUAL FEE and REPORT REOUEST
?-
Mathias Concrete Inc
./ M-1977-140
N Farm Rd Pit No 1
January 15, 2011
RECEIVED
JAN 12 2011
jp Division of Kedarnatim,
Mining and Sd*
$791.00 (Due on or before your anniversary date)
Rio Grande
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
shall submit the annual fee, a report and map showing the extent of current disturbances to affected land,
reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to occur
during the upcoming year reclamation that wwilrbe performed-during the coming year" -fit ie date's?or`the-begmmng
of active operations, and the date active operations ceased for the year, if any.
Please attach your revised written annual report and annual report man to this form. The Annual Report
& Fee requirement is not met until we have received the following components: fee, report, and associated
map. If no new disturbances or reclamation have occurred during the previous year and no new changes to
the previous year's map are necessary, then no new may is required, provided that the Operator shall state
this in the Annual Report. Please note that an adequately labeled map that clearly delineates and includes the
above elements may since for a written report.
Division records indicate the following permittee contact information. Please verify and make any necessary
changes:
Permittee Contact: Thomas G. Mathias
Permittee Name:
Address:
Phone Number:
Fax Number:
1''
Mathias Concrete Inc
1500 N. Farm Rd.
P.O. Box 266
Monte Vista, CO 81144

[phone]
[phone]
If you have additional comments and/or information that should be provided to the Division, please provide it
below or attach it to this form along with your written report and map. Annual Report instructions are enclosed.
Signature of Corporate Ofnc , Owner, or Designee
=14 P c242?
Date