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PERNMEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE <br />ANNUAL FEE DUE: <br />COUNTY: <br />ANNUAL FEE and REPORT REQUEST <br />American Gypsum Company LLC <br />M- 1984 -041 <br />Eagle-Gypsum Mine <br />December 24, 2011 <br />$791.00 (Due on or before your anniversary date) <br />Eagle <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 Your revised written annual report and annual report man 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 chap es to <br />the rreevious year's may 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: Stephen A. Onomfskie <br />Pennittee Name: American Gypsum Company LLC <br />Address: 740 Hwy 6 <br />8163 <br />Gypsum, Co 8� <br />Phone Number: (970) 524 -9700 <br />Fax Number: <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 we enclosed. <br />Z;�" 61(22— <br />Stgnatu of Cof orate Officer, Owner, or Designee <br />Z7_r /// <br />Date <br />