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;. <br />PERMITTEE NAME: <br />PERMIT NO.: <br />OPERATION NAME: <br />ANNIVERSARY DATE: <br />ANNUAL FEE DUE: <br />COUNTY: <br /> <br />ANNUAL FEE au PORT ~ UEST <br />Adams Couuty <br />t/ M-1977-283 <br />Debetz Pit <br />December 21, 2006 <br /> <br />REC~~~~~ <br />/~aR o stoop <br />p' ' ion of RbGi@ffi011@II, <br />Mining and 8®f®ty <br />$$688.00 (Due on or before your anniversary date) <br />Adams <br />operator shall submit the annual fee, a report and map showing the extent of current disturbances to affected <br />land, reclamation accomplished to date and during the preceding year, new disturbances that are anticipated to <br />occur during the upcoming year, reclamation that will be performed during the coming year, the dates for the <br />beginning of active operations, and the date active operations ceased for the year, if any. <br />Please attach your revised written annual resort and annual reuort maa to this form. The Annual <br />Report & Fee requirement is not met until we have received the following components: fee, report, and <br />associated map. If no new disturbances or reclamation have occurred durinti the previous year and no <br />new chanties to the previous year's mau are necessary, then no new map is required. provided that the <br />Operator shall state this in the Annual Resort. Please note that an adequately labeled map that clearly <br />delixieates and includes the above elements may suffice for a wrltren report. <br />Division records indicate the following permittee contact information. Please verify and make any necessary <br />changes: <br />Permittee Contact: <br />Permittee Name: <br />Address: <br />Craig Tessmer <br />Adams County <br />4955 E. 74th Ave. <br />Commerce City, CO 80022 <br />Phone Number: (303) 853-7003 <br />Fax Number: (303) 853-7015 <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 <br />c~gsed. <br />~~ <br />Signature orporate Officer, Owner, or Designee <br />O <br />Date <br />M:IPERMI7IMASTERD000MENTS~M-AF-04 <br />