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ANNUAL FEE and REPORT REQUEST <br />PERMITI'EE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br />Asphalt Constructors, Inc. <br />M-2001-069 <br />Del Norte West Valley Pit <br />November 5, 2002 <br />RECEIVED <br />ocr o ~ 2002 <br />Division of Minerals aad Geology <br />$688.00 (Due on or before your anniversary date) <br />Rio Grande <br />According to C.R.S. 34-32.5-1 16 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 />-- rectamatiorraccoinpirsited-to date and during the preceding year; new-disturbancesthat-are nnticipated-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 [he date active operations ceased for the year, if any. <br />Please attach vour revised written annual report and annual report map to this form. Please note that an <br />adequately labeled map that clearly delineates and includes the 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: Todd Stockebrand <br />Permittee Name: Asphalt Constructors, Inc. <br />Address: <br />Phone Number: <br />'Fax Number: <br />7040 W. Hwy. 160 <br />P.O. Box 449 <br />Alamosa, CO 81101 <br />(719)589-6671 <br />(719)589-0927 <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 />G/I/Ar7i.L 0.~/4/UG6~ ~ -~~~~ <br />Signature of , orate Officer, Owner, or Designe <br />3-02_ <br />Date <br />M:~PERMmhf ASTERDOCUMENTSVN-AF-01 <br />