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PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <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 />___ reclanation _accomplished_to_date_ and during the preceding year, new disturbances that are anticipated to occur <br />during the upcoming year, reclaration that will be performed during 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 />Permittee Contact: Robert Tibbetts <br />Permittee Name: <br />Address: <br />Phone Number: <br />Fax Number: <br />Acme Brick Company <br />401 Prairie Hawk Drive <br />~- Castle Rock, CO 80109 <br />(303) 688 -6951 <br />(303) 688 -9894 <br />Signature of Corporate Officer, Owner, or Designee <br />Date l B� <br />ANNUAL FEE and PORT REQUEST <br />Acme Brick Company <br />1 - 1989 -052 <br />Dakota Clay Pit <br />October 25, 2011 <br />$$323.00 (Due on or before your anniversary date) <br />Jefferson <br />BY: <br />9 4.1? <br />EC11VE <br />SEP' 0 8 2011 <br />1/ 0CT . 2 4 2011 <br />Division i and Safety Reclamation <br />A Ai�ing <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 />