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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Permittee Contact: Robert D. Oman <br />Permittee Name: <br />Address: <br />// <br />Date <br />Select Materials <br />P.O. Box 280 <br />✓ Fort Lupton,, CO`80621` - <br />Phone Number: (303) 857 -4688 <br />Fax Number: (303) 857 -4638 <br />• <br />rignature of Corporate Officer, Owner, or Designee <br />• <br />A AL FEE and r R/// RT REQUEST <br />k S lect Materials <br />(/M- 1980 -205 <br />Select Materials <br />October 2, 2011 <br />$$791.00 (Due on or before your anniversary date) <br />Weld <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- ascompl i-shed _to_date_and_durina the _preceding >y_ear, 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 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 />‘ e <br />L` <br />fr‘P 1 6 2011 <br />Division of Reciurnetion, <br />Mining and Safely <br />If you have additional comments and /or information that should be provided to the Division, please provide it <br />belo • ttach it to this • Fm - . ong with your written report and map. Annual Report instructions are enclosed. <br />