2005-07-18_REPORT - M1991147

• Permit No: M1991147
• IBM Index Class Name: Report
• Doc Date: 7/18/2005
• Doc Name: Annual Fee/Report/Map
• From: belvedere stone llc
• To: dmg
• Media Type: D
• Archive: No

1,6-JUL-2005 10:28 FROM-Colorado Division of Minerals & GealaQy [phone]
PERMITTEE NAME:
PERMIT NO.:
OPERATION NAME:
ANNIVERSARY DATE:
ANNUAL FEE DUE:
COUNTY:
T-070 P.003/003 F-172
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Belvedere Stone, LLC
M-2991-za7
Belvedere Stone Quarry
July 16, 2005
$281.00 (Due on or before your anniversary date)
Douglas
JUL 7 8 2005
Division of aiinarats & Ounlagy
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 [he atmual 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 arc anticipated to occur
during the upcoming year, reclamation that will be performed during the coming year, the dates for the beginning
of active operations, and the date active operations ceased for the year, if any_
Pleat ae ttach y~nnr revic written anneal re~nrt and anm.al rapnr~man fn this fnrm_ Please n0[e tFrat 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: William G. Johannsen
Permiltee Name: Belvedere Stone, LLC
Address: 2635 Steel Dr.
Colorado Springs, CO 80907
Phone Number: [phone]
Fax Number:

if you have additional comments and/or in:forntation 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 Repoli instructions are encloscd_
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Signature o Co o to Officer, Owner, or Designee
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Date ~